By: Dakota Guy
Ella Toth has lost count of how many times she has sat in a tattoo artist's chair. The large, elaborate pieces covering her body are a point of pride, but they have also left her feverish, nauseous, and convinced something was seriously wrong.
"There were times after a big session where I felt genuinely sick," said Toth, who has received multiple large tattoos over several years. "My skin was swollen and hot. My body was clearly reacting to something."
What Toth experienced is not unusual. Getting a tattoo is not simply a cosmetic procedure. It is a biological event that triggers a complex immune response and introduces unregulated chemicals into the body.
When a tattoo needle punctures the skin, it drives pigment past the epidermis and into the dermis hundreds of times per minute. The body responds immediately. Within two hours, white blood cells rush to the site to surround the foreign pigment. By 24 hours, immune cells called macrophages, mast cells, and fibroblasts have absorbed pigment aggregates, according to a 2016 review published in Clinical Reviews in Allergy and Immunology by researchers at the University of California, Davis.
The ink itself presents risks. The U.S. Food and Drug Administration does not regulate tattoo inks. Traditional colored inks have relied on heavy metals, such as red from mercury or cadmium, blue from cobalt, and green from chromium.
Newer organic formulations are not necessarily safer. A 2012 review in The Lancet Oncology by researchers at the University of Helsinki found that 60% of organic colorants identified in tattoos were azo compounds, some of which are classified as carcinogenic. The same review found polycyclic aromatic hydrocarbons, a known carcinogen source, present in 19 commercial black inks tested.
Red ink triggers the most reactions of any color, according to the UC Davis review. The immune mechanism is classified as a Type IV hypersensitivity reaction, a delayed T-cell response that can show up days, weeks, or even years after exposure. Standard allergy testing frequently returns false negatives because the ink must be chemically modified inside the dermis before the immune system recognizes it as a threat.
Toth said she has experienced itching and raised skin over red-inked areas that flared repeatedly, especially after sun exposure.
"It would calm down and then come back," Toth said. "I didn't think, oh, it was my tattoo that did this. It's too pretty to hurt me."
Between 1% and 5% of tattoo recipients develop skin infections, most commonly caused by Staphylococcus aureus or Streptococcus pyogenes, according to the UC Davis review. More serious complications, including toxic shock syndrome and bacterial endocarditis, have been documented, mainly from tattoos done outside of licensed parlors.
On the question of cancer, roughly 50 cases of skin cancer arising within tattoos have been reported over 40 years. Given that an estimated 80 million Americans have tattoos, the Helsinki researchers concluded the association appears coincidental, though they noted the long-term effects of newer inks remain understudied.
Toth said science has changed how she approaches the process.
"I do more research now," Toth said. "I ask about the inks. I'm not stopping, but I'm not going in blind anymore either."
References
Islam, P.S., Chang, C., Selmi, C. et al. Medical Complications of Tattoos: A Comprehensive Review. Clin Rev Allergy Immunol 50, 273–286 (2016).
Kluger, N., Koljonen, V. Tattoos, inks, and cancer. Lancet Oncol 13, e161-e168 (2012).