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Editor,

“Tattoo blow-out” is an acute complication of tattooing in which the pigments used in the tattoo spread outside the borders of the tattooed area. The phenomenon is assumed to be linked to the injection of ink into subcutaneous fat. To date, two cases concerning tattoos on the dorsum of the foot have been reported.[1, 2] This correspondence reports a new case that occurred after tattooing on the inner sides of both arms.

A healthy, 30-year-old Caucasian man had a traditional image of a sparrow tattooed on the inner side of each upper arm. He had previously been tattooed four times without complication. These tattoos, however, were his first colored ones. The tattooing procedure was unremarkable, but during the healing phase the patient noticed the persistence of an asymptomatic blue “halo” on the skin in the vicinity of the tattooed areas (Fig. 1a,b). He denied other symptoms and thought at first that the symptom marked underlying hematoma related to the procedure. The tattoos healed properly, but the lack of improvement or resolution in the discoloration prompted the subject to seek medical advice. Ink diffusion was diagnosed on the basis of the subject's medical history and clinical presentation. No biopsy was performed. A single session of laser removal by a dermatologist was unsuccessful. After four years, the discoloration has neither worsened nor spread but remained visible (Fig. 2). The patient meanwhile received another colored tattoo in another body area without complication.

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Figure 1. Tattoo blow-out after tattooing in 2007 showing (a) a blue halo around the blue sparrow on the left arm and (b) a blue halo around the other sparrow on the right arm. (The contrast has been modified digitally to increase the difference in color between the normal skin and the tattoo)

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Figure 2. Persistence of the tattoo blow-out on the left arm in 2011

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The acute complications of tattooing include pain, slight bleeding, inflammation of the surrounding skin during the procedure, transient hematoma, transiently palpable regional lymph nodes, contact dermatitis to various ointments, and pyogenic infections.[3, 4] Tattoo blow-out is an uncommon complication that occurs when tattoo pigments spread outside the borders of the tattoo to create a “blurry halo” around the tattoo. This phenomenon occurs after the deep injection of pigment ink into the hypodermis, as confirmed by biopsies of the blurry area that reveal tattoo pigment in the dermis and hypodermis.[1, 2] The complication occurs when tattoos are performed on thin areas of skin such as on the dorsum of the foot (“blue foot”)[1, 2] or penile shaft.[5] To our knowledge, this is the first reported case of tattoo blow-out on an upper limb. The thickness of the epidermis ranges from 0.1 mm to 4.0 mm, depending on location, whereas the dermis is 20 times thicker and may reach a thickness of 3–4 mm.[6] During tattooing, pigments are injected 1–2 mm into the dermis, where they will remain throughout the lifetime of the bearer.[7] It is thus quite likely that in areas of thin skin, the pigments are mechanically introduced into the hypodermis. The frequency of tattoo blow-out is undoubtedly underestimated as it is a topic of discussion in specialized Internet tattoo forums.[5] The phenomenon is acute and rapidly visible.[1] It should not be confused with the natural aging of the tattoo, in which the borders of the tattoo become blurry after several years as a result of a combination of sun exposure, the progressive assimilation of pigments by macrophages, and macrophage migration in the dermis towards lymphatic vessels.[4] Tattooed individuals prefer to seek the advice of their tattooists, who usually speculate that the discoloration is related to deep diffusion of the ink in or under the skin. It is therefore difficult to determine whether this phenomenon is restricted to only blue dyes. It is most likely that affected individuals seek medical treatment only if the discoloration is peculiarly intense and unattractive. However, others may decide to have the tattooist tattoo over the discoloration. Potential mechanisms of diffusion include capillary action through subcutaneous fat, and vascular, lymphatic, or fascial spread.[3] However, histology has thus far failed to show any evidence of lymphatic or vascular involvement.[1, 2] The chemical properties of the ink may also play a role in ink diffusion in subcutaneous fat, as will the tattooist's experience and skills. Indeed, the author has also encountered localized tattoo blow-out on the thigh of an individual who underwent Samoan tattooing with traditional tattooing tools and on the wrist of a young woman within 24 hours of tattooing in a professional tattoo parlor (N. Kluger, unpublished data, 2011). It can be speculated that the tattooist's technique and the use of “traditional” tools may have played a role in introducing pigments deep into the skin. The first patient was contacted several years later and confirmed that the halo was still present, but he refused any treatment. The second patient had her tattoo removed surgically. The surgeon stated that exogenous pigments were also located on the tendons of the patient. Management by Q-switched laser was effective in treating the tattoo blow-out in the two previously reported cases.[1, 2] In the present case, it is not clear that laser removal was ineffective; unfortunately, the parameters and type of laser used could not be recovered.

Tattoo blow-out is most likely an underestimated acute complication of tattooing. Physicians should be aware of this complication in order to reassure patients and choose adequate Q-switched laser therapy. The potential side effects of pigments located under the dermis in the long term have not been assessed.

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