Tattooing has been in practice since millenniums across the globe for various purposes like art and beautification. The tattoo regret is also on a rise with an increase in tattooing. We herein illustrate two cases of dermatological diseases, namely vitiligo and morphea, wherein patients got them tattooed hoping to camouflage them, but ended up with tattoo regret.
A 24-year-old female presented with complaint of white patches over face since the last 2 years. These white patches started over the forehead, were insidious in onset and gradually progressive in nature. They were diagnosed as vitiligo, and on treatment, the disease got stable and remained stable for almost 9 months. There was no history suggestive of autoimmunity in person and family. She then got the lesions tattooed from a local tattoo artist for camouflaging around 6 months ago, when her friends and relatives influenced her about the tattoos. But the tattooing reactivated the disease and led to an increase in size of the older lesions and eruption of new lesions. On cutaneous examination, depigmented patches of variable sizes present over glabella area extending to dorsum of nose 3 × 3 cm, above lateral aspect of eyebrows 1 × 1 cm, right cheek 6 × 5 cm extending to philtrum, left ala of nose and involving upper lip, left cheek 2 × 2 cm, with leucotrichia of eyelashes. Purple pigmented tattooing was noticed in most of the patches and depigmented patches are seen extending beyond tattooed area [Figure 1]. Rest of the cutaneous, scalp and genital examination were normal.
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Figure 1: Depigmented patches of vitiligo of variable sizes present over forehead, and both cheek with leucotrichia of eyelashes. Purple pigmented tattooing is seen in most of the patches and vitiligo patches are seen extending beyond tattooed area
In another scenario, a 23-year-male came with complaint of hyperpigmentation over right mandibular area extending to behind the ear since 6 years. These lesions were sudden in onset, gradually progressive in nature. There was no history of prior trauma and injection at this site. The patient was clinically diagnosed as plaque morphea and treated with topical tacrolimus 0.1% ointment from a dermatologist. The lesion stopped spreading and showed some improvement after which the patient stopped treatment. The disease remained stable for almost 2 years till 8-9 months back, when the patient got the left over lesion tattooed from local tattoo artist for the purpose of camouflaging when his friends told him about the beneficial effect of tattooing on limiting the disease. Since then, the lesion progressed rather rapidly to involve the surrounding area. Cutaneous examinations revealed well defined, hyperpigmented, indurated plaque of size 7 × 5 cm with lilac borders extending from preauricular area to right mandibular till retroauricular area with central area showing green pigment tattoo [Figure 2]. Rest of the systemic examinations were normal. Skin biopsy done at our centre was suggestive of morphea.
Figure 2: Hyperpigmented, indurated plaque with lilac borders extending from preauricular area to retroauricular area with green tattoo pigment in the centre
Recently, tattooing has become popular particularly among the youngsters as a fashion statement, improvement of body image and as an expression of affection towards their loved ones.[1] A study done by Latreille et al.[2] found that 44% got their tattoo before 18 years, 39.1% had amateur tattoo. Moreover, the common reasons for tattooing were imitation or influence of entourage (24%), aesthetic reasons (21%) and sentimental reasons (20%). In a study from North-east India, common reason for tattooing noted were fashion, fun and peer pressure in 87.7%, 6.6% and 4.7% of the participants, respectively.[1] As tattoos become more common, so does tattoo regret. In previous studies, it has been seen that 16-44% of people with tattoos, for various reasons, later regret at least one of their tattoos.[34] The most common motivation for removal of a tattoo was enhancement of self-esteem. Other reasons for removal, such as eradication of a socially discrediting lesion, domestic pressure and improvement of employment prospects.[4] Another study done in North-east India on tattoo practices revealed that the most common reason for tattoo removal was to be eligible for armed force jobs (49.5%), followed by regret (21.7%), elder or school pressure (14.2%), personal (12.7%) and unsightly appearance such as hypertrophic scarring in tattoo (1.9%).[1] Our patients saw tattoo as an attractive prospect as it would mask their cutaneous lesion, since the appearance can be quite embarrassing in a society laden with misconception. Our patients also held a false belief that tattooing would limit their disease. Unfortunately, both our patients suffered from diseases that are known to exhibit Koebner's Phenomenon. And the tattooing led to reactivation of the disease and increase in the size of their lesions rather than its limitation. We reviewed the literature for any such previous report but were unable to trace any such instance.
Micro-pigmentation/tattooing has been recommended for camouflage in recalcitrant lesions of vitiligo, especially over distal digits, lips, hands, wrists, axillae, elbows, perianal areas, lower legs, mucosae and mucocutaneous junctions.[5] However, it can be performed only in resistant, stable and localized vitiligo.[6] Tattoos are not without risk after all. Patients are at risk for developing infections, allergic contact dermatitis, pseudolymphoma, and inflammatory reactions.[7] Therapeutic tattooing may also end up in tattoo regret due to difficulty in getting an exact color match or gradual colour fading.
Decision for micropigmentation/tattooing for therapeutic purpose should therefore be based upon proper selection of patient, stability of disease, the site of lesion, and must be performed by a dermatologist. Moreover, an exposed site of involvement like face in our patients should further stimulate us to either assess the psychiatric impact in detail or seek expert psychiatrist opinion. Such patients need proper counselling to relieve their stress to the extent that they stay away from such harmful procedures. Counselling remains an important part of the disease management, however common or trivial it might seem to a dermatologist.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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