Posted: Aug 22, 2012 3:00 PM by By Alan Mozes
WEDNESDAY, Aug. 22 (HealthDay News) -- A recent outbreak of skin infections among 19 tattoo customers in the Rochester, N.Y., area was likely caused by a contamination of the premixed and prepackaged tattoo ink purchased by a single tattoo artist, and not due to any unhygienic practices of the facility itself, investigators have determined.
The ink had been contaminated during production with an uncommon type of bacteria called Mycobacterium chelonae or M. chelonae, researchers found. As a result, during the fall and winter of 2011, otherwise healthy men and women developed raised and persistent rashes at the site of their tattoos within three weeks of their inking procedures in New York.
Investigations in several other states have confirmed similar infections in Washington, Iowa and Colorado.
"Given the apparent popularity of tattoos, we advise people who have gotten a tattoo and who then develop a rash to not ignore it, but rather be evaluated by a physician because many of these infections can become serious and will not resolve without proper treatment," said study lead author Dr. Byron Kennedy, health director of the Monroe County Department of Public Health, in Rochester.
Such cases raise concerns that improper ink production could undermine patrons' safety even when tattoo parlors adhere to best practices and standards.
"Public health officials don't have good data on how common tattoo-related infections are because in many states tattooing remains an unregulated activity," Kennedy said.
"Given that our investigation led to the discovery of outbreaks in several other states, it seems reasonable to conclude that such infections, while not common, are not rare," he added.
The findings were published online Aug. 22 in the New England Journal of Medicine.
The U.S. Centers for Disease Control and Prevention reports that roughly one in five American adults has at least one tattoo. The CDC recommends that manufacturers produce sterile ink and that such ink not be diluted with non-sterile water at the time of tattooing.
However, the U.S. Food and Drug Administration does not require that such inks be sterile.
The investigation started in January after a dermatologist notified the health department of the case of a 20-year-old Rochester resident with a lingering skin infection that set in following a single tattoo session.
The man -- who had undergone a number of prior tattoo sessions without incident -- was healthy before receiving his most recent tattoo.
After discovering that 18 other local adults (average age 35) had experienced similar post-tattoo rashes, the authors tracked down the Rochester-based tattoo parlor that all had patronized.
An inspection of the parlor found that sterile instruments had been used, clean disposable gloves were worn, no on-site ink mixing or dilutions had taken place, tap water was uncontaminated and appropriate post-tattoo care was observed.
However, interviews with the tattoo artist uncovered one common thread: All rash sufferers had been tattooed with a new pre-diluted black ink -- also known as a "gray wash" -- that the artist had been purchasing since May 2011.
The ink, which allows popular photographic shading in tattoos, had been manufactured in three different pigments and shipped in hand-mixed formulations involving distilled water, witch hazel and glycerin.
After confirming that no other local tattoo parlor used this particular ink, the team subjected the ink to a battery of laboratory tests conducted by the CDC and the New York State Department of Health. Meanwhile, the FDA conducted on-site inspections of the Arizona-based manufacturing facility, while the patients were examined by dermatologists and infectious disease specialists at the University of Rochester Medical Center.
M. chelonae was found in both opened and unopened ink bottles, and related infections were confirmed in 14 cases. Four other patients were considered "probable" cases, while one was classified as a "suspected" infection.
Most patients received antimicrobial treatments, and the rash improved, although more quickly for some patients than others. The CDC put out a nationwide outbreak alert, and the ink manufacturer voluntarily recalled the product.
Tara MacCannell, an Atlanta-based epidemiologist with the acute care team at the CDC's division of health care quality promotion, agreed that the risk is real and carries potentially substantial consequences.
"(Mycobacterial) skin infections are very hard to treat, and often require four to six months of treatment with drugs that can cause serious side effects," she noted in a CDC blog she posted on the subject. "While some people's infections may resolve just from treatment with medication, others may require multiple surgeries to remove infected tissue and may lead to significant scarring."
MacCannell suggested that tattoo artists eschew all inks not specifically intended for tattoo use, while avoiding the practice of ink dilution and the use of non-sterile water. She added that those seeking tattoos should make sure to solicit approved and registered parlors that adhere to strict hygienic guidelines, while requesting that all ink used should be manufactured solely for tattooing purposes.
The U.S. Food and Drug Administration explains what to look out for before you get a tattoo.
SOURCES: Byron S. Kennedy, M.D., Ph.D., M.P.H., health director, Monroe County Department of Public Health, Rochester, N.Y.; Tara MacCannell, Ph.D., epidemiologist, acute care team, division of health care quality promotion, U.S. Centers for Disease Control and Prevention; Aug. 22, 2012, New England Journal of Medicine, online
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