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Systematic Review

Monitoring Health Risks Associated with Body Modifications (Tattoos and Permanent Makeup): A Systematic Review

by
Desislava Bakova
1,*,
Antoniya Yaneva
2,
Stanislava Harizanova
3,
Dobromira Shopova
4,*,
Anna Mihaylova
1,
Petya Kasnakova
1,
Nikoleta Parahuleva
5,
Mariya Semerdzhieva
1,
Kostadin Bakov
6 and
Ilia Iliev
7
1
Department of Healthcare Management, Faculty of Public Health, Medical University, 4000 Plovdiv, Bulgaria
2
Department of Medical Informatics, Biostatistics and eLearning, Faculty of Public Health, Medical University, 4000 Plovdiv, Bulgaria
3
Department of Hygiene and Ecomedicine, Faculty of Public Health, Medical University, 4000 Plovdiv, Bulgaria
4
Department of Prosthetic Dentistry, Faculty of Dental Medicine, Medical University, 4000 Plovdiv, Bulgaria
5
Department of Obstetrics and Gynecology, Faculty of Medicine, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria
6
Department of Political Sciences and National Security, Faculty of Economic and Social Sciences, Plovdiv University “Paisii Hilendarski”, 4000 Plovdiv, Bulgaria
7
Centre of Technologies, Department of Biochemistry and Microbiology, Faculty of Biology, Plovdiv University “Paisii Hilendarski”, 4000 Plovdiv, Bulgaria
*
Authors to whom correspondence should be addressed.
Cosmetics 2025, 12(1), 8; https://doi.org/10.3390/cosmetics12010008
Submission received: 2 December 2024 / Revised: 30 December 2024 / Accepted: 3 January 2025 / Published: 7 January 2025
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Abstract

:
The widespread adoption of tattoos and permanent makeup across all social classes and age groups globally has led to an increase in reports of subsequent health problems. This article presents a systematic review aimed at investigating the potential health risks associated with body modifications (tattoos and permanent makeup), highlighting the need for further research and public education to bridge the gap in knowledge and ensure informed decision-making. A literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was performed in the PubMed, Scopus, Google Scholar, and ScienceDirect databases for the period between 2014 and 2024. Several significant potential health risks associated with tattoos and permanent makeup were identified: disruption of the skin microbiome, inflammatory processes and infections, allergic reactions and oncological risks, toxicity of tattoo inks, insufficient hygiene, and inadequate aftercare. Despite the prevalence of tattoos, public awareness of the possible associated complications and health risks is low. There is a need for systematic identification and assessment of health and safety risks related to body modification services, as well as the introduction of guidelines to ensure that all necessary measures are taken to prevent health hazards for both clients and professionals performing these procedures.

1. Introduction

Throughout human history, body modifications have served as significant expressive forms with diverse meanings. These practices are motivated by a variety of factors, including rituals marking the transition between life stages, protection against negative influences, expressions of belonging to specific social groups, therapeutic purposes, aesthetic enhancement, preservation of memories, and more [1,2,3]. The term body modification, derived from the English phrase, refers to any direct intervention performed on the body to bring about a change—whether temporary or permanent—in appearance or physical condition [4]. Among the oldest and most widespread forms of body modification are tattoos and permanent makeup, practices that have persisted since antiquity [5].
The meta-analysis presented here focuses specifically on these two forms of body modification. For the purposes of this discussion, the term tattooing will encompass both traditional tattoos and permanent makeup. Tattooing and permanent makeup involve the intradermal injection of specific substances for distinct purposes. Tattooing is defined as the creation of permanent markings or designs on the skin using injected products that consist of colorants and auxiliary ingredients, while permanent makeup (PMU) uses similar intradermal techniques specifically designed to enhance facial contours [6].
Historically, body modifications, particularly tattooing, have been strongly associated with specific social groups, including members of the Yakuza, individuals with criminal backgrounds, and prisoners. As a result, such practices are often perceived negatively and stigmatized within broader societal contexts. This analysis seeks to explore the evolving perceptions of tattooing and permanent makeup, examining their historical, cultural, and medical implications while providing a scientific basis for understanding their impact on modern society [7,8,9,10,11]. Inmates are among the most tattooed populations globally, even though tattooing is illegal in most prisons. Estimates suggest that 40% of inmates acquire tattoos while incarcerated, with only slight variations between countries [12,13].
Over the past few decades, there has been a notable positive shift in societal attitudes toward tattoos and permanent makeup in many developed nations [12]. Today, these forms of body modification are widely embraced across all social classes and age groups [14]. This is evidenced by the proliferation of cosmetic salons and tattoo studios worldwide. Research indicates a high prevalence of tattooed individuals aged 18 to 50, with approximately 25% in the United States, 12% in Europe and Australia, and an estimated 100 million tattooed individuals in Europe alone [15,16]. Tattoos are also highly prevalent among professional athletes, particularly in team sports such as football, basketball, and volleyball, as well as in individual sports like tennis [17,18,19,20,21]. Within these groups, tattoos often serve as a means of ego reinforcement and are associated with traits such as physical strength, aggressiveness, and rebelliousness [17].
The trend of body modifications, including tattoos and permanent makeup, is growing in popularity as a form of self-expression, especially among adolescents [22,23,24]. Other motivating factors include adherence to fashion trends, aesthetic preferences, and concerns about body image, among others. This widespread adoption highlights the shift from tattoos being viewed as markers of deviance to being celebrated as mainstream expressions of individuality and creativity [25,26,27,28,29].
Over an extended period, the practice of medical tattooing (dermatography) has demonstrated excellent outcomes across a wide range of indications. These include the management of congenital hyperpigmentation or depigmentation, dermatological conditions, trauma, and the sequelae of reconstructive surgery, encompassing both cosmetic and reconstructive applications [30,31,32,33,34].
Social contexts exert profound influence over individual decisions, often dominating many aspects of daily life and shaping decision-making processes, even subconsciously [35,36]. Some researchers suggest that body modifications, such as tattoos and permanent makeup, may correlate with specific personality traits, including sensation-seeking and impulsivity [37,38]. These traits are significant predictors of engagement in health-risk behaviors [39,40].
The prevalence of individuals with tattoos and permanent makeup continues to rise, and this trend is likely to persist [12,41,42]. The unclear identification of tattoo inks as cosmetic products or medicines, although they are injected into the skin without being authorized as sterile and injectable, is a serious issue [43].
However, despite their widespread popularity, tattoos are not without potential risks. A common misconception is that tattooing is harmless, yet complications are well documented and include allergic reactions to pigments, the formation of papular lesions, nodules, granulomas, and the exacerbation of pre-existing dermatoses [44,45,46,47]. Currently, there is a lack of comprehensive, systematic data on the frequency of health issues associated with tattooing and their progression over time. Despite the increasing prevalence of tattoos and permanent makeup, public awareness of associated health risks and complications remains low.
This article presents a systematic review aimed at investigating the potential health risks associated with tattoos and permanent makeup, highlighting the need for further research and public education to bridge the gap in knowledge and ensure informed decision-making.

2. Materials and Methods

The methodology for this systematic review was designed to adhere to established best practices, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. These standards ensured the rigor, transparency, and reproducibility of the review process [48].

2.1. Study Selection

A comprehensive literature search was conducted using multiple databases, including PubMed, Scopus, Google Scholar, and ScienceDirect. The search strategy employed a diverse set of keywords, such as body modification, body art, tattoo, tattoos, tattooing, tattooed people, permanent makeup, tattoo inks, ingredients of the ink, health risk, systematic review, skin microbiome, infection, inflammatory reactions, public health, skin health, bodily functions, regulatory framework, and legal acts regulating the use of ink for tattoos.

2.2. Eligibility Criteria

The inclusion and exclusion criteria for selecting articles were defined as follows:
Inclusion Criteria:
  • Articles published between 2014 and 2024.
  • Studies categorized as reviews, narrative reviews, systematic reviews, or meta-analyses.
  • Full-text articles available for analysis.
Exclusion Criteria:
  • Abstract-only publications.
  • Short communications.
  • Patents or policy-related documents.
  • Case reports.
  • Reports of complications not directly related to tattooing or permanent makeup.
  • Articles on temporary tattoos or makeup.
No language restrictions were applied, allowing for a broad and inclusive range of studies. The results were summarized accordingly.

2.3. Data Analysis

To standardize the data extraction and analysis, Microsoft Office Excel 2010 was utilized for developing a structured data extraction form. The process involved several stages:
  • Articles retrieved from the databases were compiled into a single Excel file, with duplicates removed.
  • Abstracts of all retrieved articles were independently reviewed by three authors.
  • From these abstracts, a shortlist of articles was created, and the full texts of the selected studies were thoroughly examined by the same authors.
  • A final selection of relevant articles was reached by consensus, following detailed discussions among all authors.
Although the primary focus was on literature published between 2014 and 2024, selected key studies from earlier years were included to provide historical context or foundational insights.
This rigorous approach to literature selection and analysis ensured that the review was comprehensive, unbiased, and representative of the current state of knowledge on the topic.

3. Results

The initial database search across PubMed, Scopus, Google Scholar, and ScienceDirect identified a total of 3760 potentially relevant scientific works, selected based on their titles. Following the removal of duplicate entries, 1432 unique studies remained for initial screening. To refine the selection, an evaluation of abstracts was conducted, which led to the exclusion of 197 articles due to insufficient data, irrelevance to the research question, or use of study strategies that did not align with the scope of this systematic review. This process resulted in 1235 full-text articles being considered for detailed analysis.
During the subsequent phase of evaluation, each full-text article was rigorously assessed for its methodological quality, relevance, and contribution to understanding the health risks associated with tattoos and permanent makeup. After this comprehensive review process, 151 full-text articles were determined to meet the inclusion criteria and were ultimately selected for inclusion in the systematic review. The study selection process, adhering to the PRISMA guidelines, is illustrated in Figure 1.

4. Discussion

Tattoos and permanent makeup are widely popular across the globe, yet there remains a significant gap in published scientific research addressing the health risks associated with these practices. The growing popularity of tattoos and permanent makeup among all social classes and age groups has coincided with an increase in reported health complications.
Epidemiological studies indicate that infectious complications (bacterial, viral, and fungal) occur in approximately 0.5% to 6% of tattooed individuals, with this percentage steadily rising [49]. Among non-infectious complications, allergic reactions are the most common and are influenced by the pigments used in tattoo inks and their potential impurities [50,51]. Tattoo inks are composed of pigments, fillers, and other components. Pigments, which can be inorganic (e.g., iron oxide, titanium dioxide) or organic (e.g., azo and polycyclic pigments), have specific impurities, such as heavy metals in inorganic pigments and aromatic amines in organic ones. Carbon black is a commonly used pigment with potential polycyclic aromatic hydrocarbons (PAHs) impurities [52].
Moreover, some researchers have raised concerns regarding the presence of potentially immunotoxic, mutagenic, or carcinogenic substances in tattoo inks, such as azo dyes. These substances may contribute to the development of certain diseases, although definitive causal relationships remain to be fully established [53].
In addition to these chemical risks, tattoos are associated with a variety of complications that can significantly impact the quality of life. Allergic reactions, in particular, often dominate as a primary concern, manifesting as localized or systemic symptoms that may persist or recur over time [54,55,56].
These data underscore the importance of continued research and public education on the potential health risks of tattoos and permanent makeup. A more comprehensive understanding of the associated risks is essential for developing safer practices and regulatory measures to minimize complications.

4.1. Disruption of the Skin Microbiome

According to the International Classification of Medical Treatment Methods, tattooing is categorized as a surgical intervention [57]. Despite the invasive nature of the procedure, tattoo inks are typically not subject to the stringent safety regulations applied to substances like pharmaceuticals or implants [53,58,59].
During tattooing, ink is injected between the epidermal and dermal layers of the skin using needles. Historically, this procedure was performed manually, using tools such as bones, metal implements, and needles, until the late 19th century. Modern tattooing employs specialized tattoo machines that enable more efficient ink application.
The penetration of needles disrupts the subcutaneous tissue layers and significantly impacts the skin microbiome, which plays a critical role in maintaining overall skin health [60]. Often referred to as the “fourth layer of the skin,” the human skin microbiome encompasses diverse bacterial, fungal, and viral populations that interact closely with the epidermal and dermal layers. This microbiome is fundamental to skin physiology and immune defense [61,62].
While the dermis retains the structural integrity of the skin, the epidermis serves as the primary protective barrier in direct contact with the external environment. This barrier comprises numerous biological, structural, and chemical elements, including the microbial communities that are crucial for preventing internal infections. Disruptions to the skin barrier—due to trauma, pathology, aging, or interventions like tattooing—can lead to microbial dysbiosis, increasing the risk of infection and other complications [63,64,65].
Dermatologists have long recognized that certain skin conditions (e.g., atopic dermatitis, psoriasis) and manipulations can compromise the integrity of the skin microbiome [66,67,68].
However, the impact of specific interventions—such as surgical excision, dermabrasion, laser therapy, and tattooing—on the balance of the skin microbiome, particularly on the quantity and composition of beneficial microorganisms, remains insufficiently studied [69].
Understanding the long-term effects of tattooing and similar invasive procedures on the skin microbiome is crucial, given its essential role in skin health, immune function, and the prevention of infection. Further research is needed to clarify these effects and establish guidelines to mitigate potential risks.

4.2. Inflammatory Processes and Infections

The tattooing process inherently involves intentional skin injury, which may result in a range of complications such as superficial and deep infections, systemic inflammatory reactions, eczema, psoriasis, lichen planus, photodermatitis, and other conditions [70,71].
The breach of the epidermal barrier during tattooing creates an entry point for microbial pathogens. These pathogens can lead to localized wound infections and, in some cases, systemic complications [72].
Adverse reactions may occur immediately after the procedure or persist as chronic infections, as pigments and their contaminants can enter the bloodstream through the dermal vascular system [54,73].
Studies have demonstrated that while a portion of the tattoo pigment remains at the injection site, nanoparticles of the pigment can migrate to lymph nodes via the bloodstream. These particles may also be transported to and accumulate in larger organs, potentially carrying impurities present in the ink [74,75,76,77]. Recently, researchers have identified the deposition of metal debris from tattoo needles in the skin and local lymph nodes, raising additional concerns [59,78].
Tattoo needles, which often contain high levels of nickel and chromium, may release metallic debris during the procedure. This debris increases the risk of sensitization and allergic reactions, compounding the potential health risks associated with tattooing [79].
The growing popularity of tattoos and permanent makeup (PMU) has been accompanied by an increase in reported cases of infection [41,80]. Epidemiological studies estimate that infectious complications—including bacterial, viral, and fungal infections—occur in 0.5% to 6% of tattooed individuals, with this percentage steadily rising [57,81,82].
This evidence underscores the need for heightened awareness of the health risks associated with tattooing, stricter safety regulations, and further research into the mechanisms by which tattoos may contribute to systemic and localized health complications.

4.3. Allergic Reactions and Oncological Risks

Allergic reactions are the most common complications associated with tattooing [83,84,85,86]. Tattoo ink allergies may occur immediately or may be delayed, possibly occurring years after the individual has been tattooed.
One frequently observed allergic manifestation is the formation of granulomas, localized inflammatory responses at the tattooed site [87]. These granulomas are often confined to the tattooed area and can appear either as a single lesion covering the entire pigmented region or as multiple small nodules within the affected area. Red tattoo ink is most commonly implicated in granuloma formation. In some cases, contaminated tattoo ink can lead to atypical mycobacterial infections, resulting in painful, itchy, and inflamed pustules at the tattoo site [88].
Diagnosing allergic reactions to permanent tattoo ink can be very challenging [89].
Moreover, some reactions mimic skin cancer, with lesions resembling squamous cell carcinoma occurring within the pigmented region [75].
Tattoo pigments, especially those containing organic and inorganic compounds, have been shown to induce chronic inflammation at deposition sites [90,91,92]. This persistent inflammatory state may increase the risk of abnormal cell proliferation, potentially leading to skin cancers such as melanoma and non-melanoma skin cancers, as well as lymphomas [92,93,94]. Additionally, tattooing may elicit systemic immune responses, contributing to an elevated risk of hematologic malignancies [95,96,97,98,99,100,101,102].
Black tattoo ink is of particular concern as it consists of soot particles, including polycyclic aromatic hydrocarbons (PAHs) such as benzo(a)pyrene (BaP)—a known carcinogen [103]. The physiological responses to tattoo pigments are highly complex, involving a mixture of factors such as
➢
The composition of pigments (including their organic and inorganic components).
➢
Photosensitive reactions caused by exposure to ultraviolet (UV) light.
➢
Inflammatory and immune-mediated responses.
➢
Histopathological diversity in lesion presentations.
➢
Individual lifestyle and genetic predispositions.

Systematic Classification of Adverse Effects

Given the rising prevalence of tattoo-related complications, international experts such as Serup et al. have proposed a systematic classification system for adverse effects [52,104]. Based on a retrospective monocentric study evaluating 493 complications in 405 tattooed patients, this classification integrates diagnostic levels (Levels A and B, aligned with WHO Diagnostic Classifications) and groups complications into the following categories:
➢
Infections
➢
Inflammatory conditions
➢
Psychosocial effects
➢
Other miscellaneous reactions
➢
Treatment-related effects
This classification system was adopted as a proposal for inclusion in the 11th Revision of the International Classification of Diseases (ICD-11) by the World Health Organization (WHO) [105,106].
These findings highlight the need for more stringent regulatory oversight, comprehensive public awareness campaigns, and further research into tattoo-related allergic and oncological risks.

4.4. Toxicity of Tattoo Inks

One of the most common non-infectious complications of tattooing includes allergic reactions to the pigments or heavy metals (primarily chromium and nickel) present in tattoo inks [85,107]. Additionally, some researchers have highlighted the presence of immunotoxic, mutagenic, carcinogenic compounds and azo dyes in tattoo pigments as potential contributors to disease development [53,108]. Consequently, the composition of tattoo inks is considered a primary source of health risks [109,110,111].

4.4.1. Evolution of Tattoo Inks

Historically, tattoo inks were derived from natural pigments, such as the Lawsonia inermis plant extract, which was commonly used for tattooing decades ago [112]. However, in modern tattooing, synthetic pigments dominate due to their cost-effectiveness and the ability to produce a broader range of colors [11,113,114].
Presently, tattoo inks with unclear origins and content are widely used due to the lack of unified international standards for their production. These inks are complex mixtures containing over 100 compounds, including pigments, solvents, thickeners, preservatives, and impurities [53]. Although manufacturers are required to provide detailed ingredient information, compliance is inconsistent, posing significant health risks [115,116].

4.4.2. Risks Associated with Ink Contamination

Tattoo artists and cosmeticians often purchase inks online or from local suppliers, which increases the likelihood of obtaining unregulated products [117,118]. Compounding the issue is the widespread use of reusable containers for ink storage and transportation, raising concerns about contamination.
Scientific studies have identified the presence of both aerobic and anaerobic bacteria in tattoo and permanent makeup inks stored under various conditions [119]. Notably, even factory-sealed inks have been found to harbor anaerobic bacteria, which thrive in low-oxygen environments like the dermis, alongside aerobic bacteria. Contaminated inks are therefore a potential source of dual bacterial infections.

4.4.3. Challenges in Assessing Long-Term Health Risks

The lack of comprehensive scientific studies on the long-term effects of tattoo inks and their active compounds on human health limits our ability to assess associated risks. Key challenges in conducting such research include the following:
➢
Variability in ink composition: Pigments and harmful impurities can differ significantly between products.
➢
Unquantifiable amounts of ink introduced: It is difficult to precisely measure the volume of pigments deposited into the dermis during tattooing.
➢
Unknown toxicological profiles: Limited data exist on the potential interactions between tattoo pigments and the body over time.
These gaps highlight the urgent need for standardized regulations, robust safety testing, and long-term epidemiological studies to ensure the safety of tattoo inks and protect public health [109].
Given the increasing concerns regarding the presence of harmful components in tattoo inks, it is advisable to establish minimum safety standards for these inks in the marketplace and implement routine testing using validated methods. It is important to note that the toxicity of different components in tattoo inks, particularly when injected and stored under the skin, is not always fully understood. As a result, it is anticipated that future developments will focus on investigating the toxicological effects of tattoo ink components, both in vitro and in vivo [120].
Scientific studies have demonstrated that certain colors, particularly red, green, yellow, and blue, exhibit higher allergenic potential compared to others [121,122]. Many contemporary tattoo inks also contain organic azo dyes with plastic-based pigments, which are also used in industrial applications such as printing, textiles, and automotive paints [59,109,110].
However, the lack of standardized test methods for analyzing tattoo inks and assessing their safety remains a significant issue [123,124]. To address these concerns, several Resolutions on Requirements and Criteria for the Safety of Tattoos and Permanent Makeup (ResAP2003 and ResAP2008) were introduced in Europe to regulate tattoo and permanent makeup safety. As of January 2022, the European Union (EU) has restricted over 4000 potentially hazardous substances from use in tattoo inks. These banned substances include specific pigments (notably all currently used green and blue colors) and solvents [84]. Tighter EU restrictions also include lower thresholds for metallic impurities introduced through pigment manufacturing. These changes in the usability of specific chemicals and impurity thresholds pose tremendous challenges for the tattoo ink industry [125,126,127,128].
Despite these resolutions, effective implementation across all European countries remains limited. In contrast, Canada and the USA have largely left tattoo inks unregulated [84,129].
As of now, there are still numerous unknowns regarding how these inks interact with the skin and whether they contribute to the rising number of complications associated with tattoos and permanent makeup [43,59,117,130]. This highlights the need for continued research and the establishment of universal safety regulations to ensure the health and safety of consumers.

4.5. Hygiene and Aftercare

Another significant source of danger can be the lack of sufficient hygiene in the tattoo studio or salon and inadequate aftercare for injuries caused by non-medical professionals [131,132].
Infections may develop during the wound healing process or as a result of improper treatment after the tattoo is applied [133]. Aftercare for tattoos is essential for proper wound healing and to prevent infection and irritation.
Pathogens can be introduced through contaminated instruments, ink, or the tattoo artist’s saliva. In some cases, tattoos may be placed on already infected skin [134,135]. If proper disinfection is not performed, there is a high risk of transmitting bloodborne pathogens such as hepatitis and HIV [136,137,138].
According to Gębska-Kuczerowska et al. (2021), the risk of transmitting certain diseases due to non-sterile needles should not be underestimated [103]. These diseases include skin cancer, HIV, hepatitis B, hepatitis C, herpes, smallpox, tetanus, tuberculosis, and staphylococcal infections [139,140].
Other authors suggest that tattoos can lead to Streptococcus pyogenes infections, which can cause impetigo, erysipelas, and sepsis [141,142]. The bacteria Staphylococcus aureus can cause rare toxic shock syndrome, while methicillin-resistant Staphylococcus aureus (CA-MRSA) can result in skin infections and soft tissue infections. The bacterium Treponema pallidum can lead to syphilis, and Mycobacterium leprae can cause leprosy.
Symptoms associated with skin infections include but are not limited to redness, itching, local swelling, and general discomfort. If the infection spreads, additional symptoms may appear [141,143,144,145]. Proper hygiene and aftercare are crucial to prevent these infections and ensure the safe healing of the tattoo.
The increasing concern is fueled by the fact that most individuals do not seek prior information regarding the contents of tattoo inks, the associated health risks, aftercare procedures, and other critical factors [110,146,147,148]. Tattoo aftercare instructions describe how to care for a tattoo. Unfortunately, tattoo artists often base their advice on personal experience rather than best practices in medical wound management. The diversity of recommendations in these instructions is currently unknown [149].
Furthermore, additional challenges arise due to the lack of a systematic training framework for tattoo artists that could enhance their knowledge of health-related issues [150,151].
The introduction of educational initiatives for tattoo artists could help bridge gaps in healthcare by implementing successful screening processes for clients [152]. Such initiatives could enable tattoo artists to better identify potential health problems and encourage clients to seek medical attention when necessary. In turn, this would facilitate the early diagnosis and more effective treatment of various diseases [153,154,155].
Despite the widespread popularity of tattooing, there is still a lack of unified, specific regulatory frameworks regarding the hygiene standards for the products used, the tools employed in tattooing, and professional competence (health knowledge and skills) of the staff in tattoo studios [155]. This regulatory void poses significant risks to both clients and practitioners, which could be mitigated through the establishment of clear standards for training, hygiene practices, and health regulations.
The synthesized analysis of these studies provided valuable insights into the most significant potential health risks associated with body modifications such as tattoos and permanent makeup. These findings, which represent a consolidation of the most critical data points from the reviewed literature, are systematically summarized in Table 1.
Figure 2 provides an overview of the potential health risks linked to body modifications, including tattoos and permanent makeup, and outlines safer practices alongside regulatory measures aimed at minimizing complications. The figure highlights key risks such as infections, allergic reactions, toxicity of materials, and poor hygiene. It also suggests strategies like adherence to strict hygiene protocols, the use of non-toxic, approved pigments, thorough practitioner training, and post-procedure care. Additionally, it underscores the importance of regulatory oversight, public education, and informed consent in reducing the likelihood of adverse outcomes.

5. Conclusions

The tattooing process is associated with significant health risks. The growing popularity of tattoos and permanent makeup is captivating the minds of an increasing number of individuals globally, and many fail to consider the potential health risks that could arise from introducing ink under the skin. Questions such as “What is the hygiene standard of the studio?”, “What inks are being used?”, “How is the equipment sterilized?”, “What are the potential health risks?”, and “What are the potential benefits (physical, emotional, and social) of such body modification practices?” often remain unanswered or unclear.
This highlights the importance of addressing this issue in terms of public health protection. It is crucial that individuals undergoing such procedures are well informed. At present, there is a lack of scientifically based information at the world level about the possible risks associated with body modifications (tattoos and permanent makeup). Given that these practices are most popular among adolescents and young adults, it is essential to provide all opportunities for informed decision-making through appropriate channels. Making an informed decision about where to go for tattoo is important to reduce the risks of tattoo ink allergy; going to a reputable artist who is knowledgeable about tattoo ink ingredients and has good knowledge of health and safety guidelines can help avoid the development of tattoo ink health risks.
Clinical observations and existing scientific literature clearly demonstrate that tattoo inks can have harmful effects on skin health, body functions, and cause complications over time. However, the impact of tattoo inks on the skin microbiome has not yet been investigated for toxicity levels. This underscores the need for future research exploring how physical and chemical interventions (tattooing and the inks used) may potentially disrupt the skin microbiome and track their long-term effects.
The results of the current meta-analysis are likely to have adverse economic consequences for the tattoo industry, but understanding the potential negative side effects on health requires proactive engagement from specialists. Therefore, in-depth studies on the effects of substances in tattoo inks and the assessment of the risks of indirect allergic reactions and potential carcinogenic effects are necessary. Systematic identification and evaluation of health and safety risks associated with body modification services are crucial, as is the formulation of recommendations/guidelines for implementing all necessary measures to prevent health hazards, for both clients and the professionals performing these procedures.
Introducing requirements for professional competence for individuals performing these procedures, as well as enforcing stricter control over ink composition and hygiene standards, will ensure optimal safety for public health. It is also necessary to bring together medical, educational, legal, and other professionals in an interdisciplinary discussion focused on body modifications (tattoos and permanent makeup). International experience is essential not only for creating new legal principles but also for establishing clear rules to protect health and ensure safety.

Author Contributions

Conceptualization, D.B. and A.Y.; methodology, A.M. and M.S.; software, P.K.; validation, D.S. and N.P.; formal analysis, S.H.; investigation, A.M.; resources, M.S. and N.P.; data curation, S.H.; writing—original draft preparation, D.B. and A.M.; writing—review and editing, D.S. and K.B.; visualization, A.Y. and P.K.; supervision, I.I.; project administration, I.I.; funding acquisition, K.B. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflicts of interest.

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Cosmetics 12 00008 g001
Figure 1. PRISMA flow chart of the study selection process.
Figure 1. PRISMA flow chart of the study selection process.
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Figure 2. Strategies to minimize health risks associated with body modifications (tattoos and permanent makeup).
Figure 2. Strategies to minimize health risks associated with body modifications (tattoos and permanent makeup).
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Table 1. Health risk related to body modification (tattoo and permanent makeup).
Table 1. Health risk related to body modification (tattoo and permanent makeup).
Key Benefit/TopicArea of Application/SignificanceReferences
Disruption of the Skin MicrobiomeDisruption of the subcutaneous tissue layers significantly impacts the skin microbiomeKong, 2011 [60]
Lead to microbial dysbiosisZeeuwen et al., 2012; Howard et al., 2022; Nho et al., 2020 [63,64,65]
Increase the risk of infection and other complicationsZeeuwen et al., 2012; Howard et al., 2022; Nho et al., 2020 [63,64,65]
Inflammatory Processes and InfectionsTattoo inks may result in deep infections, systemic inflammatory reactionsBălăceanu-Gurău et al., 2024; Chalarca-Cañas et al., 2024 [70,71]
Pathogens can lead to localized wound infectionsSerrano-Serra et al., 2021 [72]
Pigments and their contaminants can enter the bloodstreamIslam et al., 2016; Giulbudagian et al., 2024 [54,73]
The pigment can migrate to lymph nodes; may also be transported to and accumulate in larger organsEngel et al., 2010; Kurz et al., 2023; Lehner et al., 2014; Tamura et al., 2019 [74,75,76,77]
The metal debris from the tattoo needles increases the risk of sensitization and allergic reactionsSchreiver et al., 2019 [79]
Allergic Reactions and Oncological RisksAllergic reactions to tattoo ink are the most frequent tattoo complicationDieckmann et al., 2016; Klügl et al., 2010; Tampa et al., 2022 [57,81,82]
Contaminated tattoo ink can lead to atypical mycobacterial infectionsSchubert et al., 2024 [88]
Increasing of the risk of abnormal cell proliferation, potentially leading to skin cancers such as melanoma and non-melanoma skin cancers, as well as lymphomasFoerster et al., 2020; Clemmensen et al., 2024; Hosseini et al., 2024 [92,93,94]
May elicit systemic immune responses, contributing to an elevated risk of hematologic malignanciesLyons et al., 2018; Berkowitz et al., 2020; Ghorpade, 2015; Bonifazi et al., 2015; Jammal et al., 2020; Sabbioni & Hauri, 2016; McCarty et al., 2024; Swerdlow et al., 2017 [95,96,97,98,99,100,101,102]
Toxicity of Tattoo InksThe composition of tattoo inks is considered a primary source of health risks Negi et al., 2022; Rahimi et al., 2018; Di Gaudio et al., 2023 [109,110,111]
The manufacturers of tattoo inks do not provide detailed ingredient information, posing significant health risksAbed et al., 2024; Paola et al., 2016 [115,116]
Contaminated inks are a potential source of aerobic and anaerobic bacterial infectionsYoon et al., 2024 [119]
Need for standardized regulations, robust safety testing, and long-term epidemiological studies to ensure the safety of tattoo inks and protect public health Negi et al., 2022 [109]
There are still numerous unknowns regarding how these inks interact with the skinAndreou et al., 2021; Karadagli et al., 2022; Bäumler, 2020; Kluger, 2021 [43,59,117,130]
Hygiene and AftercareThe lack of sufficient hygiene in the tattoo studio can be significant source of dangerCohen, 2021; Gębska-Kuczerowska et al., 2020; Serup, 2017 [136,137,138]
Aftercare for tattoos and permanent makeup is essential for proper wound healing and to prevent infection and irritationLiszewski et al., 2016; Rostron et al., 2015 [132,133]
Most individuals do not seek prior information regarding the contents of tattoo inks, the associated health risks, aftercare procedures, and other critical factors Rahimi et al., 2018; Notara et al., 2022; Rogowska et al., 2018; Liszewski et al., 2023 [110,146,147,148]
There is a lack of a systematic training framework for tattoo artists, which could enhance their knowledge of health-related issues Serup, 2015; Kühn et al., 2023 [150,151]
The introduction of educational initiatives for tattoo artists could help bridge gaps in healthcare by implementing successful screening processes for clients Verma et al., 2024; Monfrecola et al., 2023; Bassi et al., 2014; Fels et al., 2023 [152,153,154,155]
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Bakova, D.; Yaneva, A.; Harizanova, S.; Shopova, D.; Mihaylova, A.; Kasnakova, P.; Parahuleva, N.; Semerdzhieva, M.; Bakov, K.; Iliev, I. Monitoring Health Risks Associated with Body Modifications (Tattoos and Permanent Makeup): A Systematic Review. Cosmetics 2025, 12, 8. https://doi.org/10.3390/cosmetics12010008

AMA Style

Bakova D, Yaneva A, Harizanova S, Shopova D, Mihaylova A, Kasnakova P, Parahuleva N, Semerdzhieva M, Bakov K, Iliev I. Monitoring Health Risks Associated with Body Modifications (Tattoos and Permanent Makeup): A Systematic Review. Cosmetics. 2025; 12(1):8. https://doi.org/10.3390/cosmetics12010008

Chicago/Turabian Style

Bakova, Desislava, Antoniya Yaneva, Stanislava Harizanova, Dobromira Shopova, Anna Mihaylova, Petya Kasnakova, Nikoleta Parahuleva, Mariya Semerdzhieva, Kostadin Bakov, and Ilia Iliev. 2025. "Monitoring Health Risks Associated with Body Modifications (Tattoos and Permanent Makeup): A Systematic Review" Cosmetics 12, no. 1: 8. https://doi.org/10.3390/cosmetics12010008

APA Style

Bakova, D., Yaneva, A., Harizanova, S., Shopova, D., Mihaylova, A., Kasnakova, P., Parahuleva, N., Semerdzhieva, M., Bakov, K., & Iliev, I. (2025). Monitoring Health Risks Associated with Body Modifications (Tattoos and Permanent Makeup): A Systematic Review. Cosmetics, 12(1), 8. https://doi.org/10.3390/cosmetics12010008

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