Permanent tattooing has become increasingly more popular in Europe and Western countries (Kluger, 2013). As the popularity of tattoos increases in today’s society, it becomes imperative that healthcare professionals prepare to care for tattoos (Kluger, 2013). Currently, there is a lack of standardization within the tattoo industry for the care of tattoos during the healing stages, also called “aftercare” within the tattoo industry (Fox, McNichols, Gowda, & Motamedi, 2004). Until healed, tattoos are essentially large dermal wounds that require routine care (Greif & Hewitt, 1998). Nurses are taught wound care essentials, but tattoos are special wounds because of the pigments and locations on the body. The healing time for tattoos often differs from location to size, and tattoo wounds are susceptible to infections until healed (Greif & Hewitt, 1998).
REVIEW OF LITERATURE
Massahel and Musgrove (2009, p. 8) defined tattooing as “a permanent picture, design, or other markings made on the skin by pricking it with a sharp implement and staining it with indelible dye.” The process of tattooing involves introducing dyes or exogenous pigments into the dermis of an individual to produce a permanent design (Kluger, 2013). Tattooing has been practiced by many cultures and can be dated back to Egypt in 4000 to 2000 BC, a period during which tattooing was associated with fertility and nobility. Tattooing was also common in the royalty of England during the late 19th century (Messahel & Musgrove, 2009).
There is a lack of evidence to support any one aftercare method. In a randomized, controlled, double-blind study, researchers compared the use of two topical preparations: “Forever Ink Balm” and “Nappy Area Care” for tattoo aftercare (White, 2012). Forever Ink Balm was a commercially advertised tattoo ointment that contained manuka honey, which the authors described as an antibacterial agent, and Vitamins B and E. The Nappy Area Care cream was petroleum based containing lanolin and lanolin alcohol. The study’s population included healthy subjects aged 18–50 years. Subjects had either a new tattoo large enough to have two test sites measuring 3 cm × 3 cm or two separate new tattoos of adequate size and similar color. The study excluded subjects who were pregnant or had skin conditions that could alter test results as well as subjects with a known sensitivity to the ingredients in the topical preparations. Subjects taking medications such as corticosteroids or regular use of antihistamines, anti-inflammatory medications, or antibiotics were also excluded. The tool used in this study was a corneometer to measure hydration of the corneum and transepidermal water loss. The tool was stated as a reliable method to estimate hydration. Subjects applied the two products to separate areas of their tattoos and were evaluated by clinicians on Days 0, 4, 7, 11, 14, 21, and 28. The study showed no statistical differences between the interventional cream and the control cream (White, 2012).
Another study addressing the aftercare of tattoos included the use of hairless guinea pigs (Fox et al., 2004). This study looked into the procedures of tattoo placement and the aftercare of tattoos to determine which interventions will yield the most superior tattoo quality and was conducted as part of a larger study that revolved around laser tattoo removal. Because of their skin similarity to humans, researchers chose a population of 19 healthy male hairless guinea pigs. The tool used to evaluate the tattoo quality used validated a subjective scoring tool used in other skin healing studies. Three reviewers scored the tattoos on a scale of 1–5, with 1 being a uniformly pigmented tattoo and 5 being a fibrous scar. In this study, the hairless guinea pigs were tattooed using various needle sizes (3, 5, and 8 Rounds) to determine the most suitable needle for tattoo placement. After the process of tattooing the animals, three aftercare regimens were used: application of antibacterial ointment and no bandage, ointment application with gauze and cohesive bandaging left on for 5 days, and Telfa nonstick pads and ointment to be changed three times a day for 5 days. The results supported that the combination of Telfa pads and ointment for dressing change yielded the best results. A limitation of this study was the lack of human subjects. In addition, the best aftercare regimen may be because of the nature and grooming regimen of the hairless guinea pigs.
Ways of Knowing
This study into tattoo aftercare investigated the process or the way the tattoo artist came to know their aftercare method. Johns (1995) described the ways of knowing as how one acquires knowledge about the world and develops a relationship with surroundings. Johns described that the process of gaining knowledge through experience consists of several ways of knowing such as empirical, ethical, personal, and esthetic ways of knowing. Empirical knowledge refers to factual knowledge. Empirical knowledge is also described as a scientific approach to gaining knowledge (Johns, 1995). Aesthetic knowledge includes the way a person learns during life encounters, responds with a deeper understanding, and then undergoes a personal reflection. The personal way of knowing includes perception and management of the self’s feelings and prejudices. The ethical way of knowing relates to the understanding of right and wrong. Keeping in mind how learners come to know, the questions asked to the tattoo artists about how they learned their aftercare techniques centered not only around current practices but also around past practices and reasons for change. The purpose of looking at past practices, both what worked and the mistakes, is to frame learning through reflection (Johns, 1995). By allowing the artists to reflect on their experience, they are able to identify methods that are both more desirable and more effective (Johns, 1995).
An interview script was developed by the researchers to explore the desired information surrounding aftercare. Interview questions focused on current recommendations of tattoo aftercare, how the information is conveyed to clients, source of knowledge of aftercare, previous methods of aftercare, reason(s) for changing methods, place of apprenticeship, and the methods of aftercare taught during his or her apprenticeship. If participants were not specific in the description of aftercare method, he or she was prompted to give a richer description. There were also questions concerning demographic data including artist’s age and gender, length of time as a tattoo artist, and location of studio.
Tattoo artist participants were recruited for this research study through visits to local tattoo parlors and a tattoo convention. The use of a tattoo convention allowed the researchers to expand the tattoo artist pool outside the accessible area. All interviews were completed in person, and informed consent was obtained before the beginning of the interview. Participants’ answers were kept anonymous and confidential. The interview took approximately 10 minutes.
Sample and Geographic Locations
Thirty-two tattoo industry persons participated in the interviews. Of the participants, 30 were tattoo artists, and two were tattoo parlor managers. Most of the sample consisted of young men. This industry is historically male dominated; therefore, it is not unusual to have a majority be male. A quarter of the sample also had less than 5 years of experience (see Table 1).
The sample included a variety of areas of the United States. The location of the parlor in which the participant artists worked included 72% in the South Eastern United States including South Carolina, North Carolina, Kentucky, Florida, and Georgia. Nine percent were located in the North Eastern United States including Maine, New York, and Pennsylvania. Thirteen percent were located in Illinois, and one participant was from Oregon. Also of note, one participant stated he traveled to tattoo conventions and had no home studio.
The data on participants’ recommendations for aftercare included cleaning practice (soap, water temperature, and routine), dressings, and a moisture method (see Table 2).
Most participants did not specifically tell clients what kind of soap to use, the temperature of the water, or the times per day to wash. Five participants recommended mild soap, and nine recommended antibacterial soaps. Only seven participants recommended how to dry the tattoo. Three participants told clients to air-dry their tattoo, one participant recommended the use of a clean towel, and three recommended the use of a paper towel.
Artists’ recommendation for dressing a completed tattoo also varied. Most of the artists sampled did not recommend covering the tattoo. Eight participants recommended the same plastic wrap used in cooking to dress the tattoo, and two of the participants recommended using dry lock pads similar to pads that absorb blood in meat packs. One artist recommended a nonstick absorbent pad for a short period after the tattoo is finished, whereas another recommended using a Tegaderm occlusive dressing for 3 days and then dry heal after removal.
There were also a wide variety of recommendations for moisture methods, and many of the participants used combination methods for healing. Almost a third of the sample used petroleum-based ointments. Many of the participants specifically stated that they used the trade name ointment “Aquaphor.” Eleven others used commercial lotion products primarily unscented. Seven participants suggest that clients use tattoo-marketed ointments, which are ointments made specifically for tattoo care such as the trade names “H2otion” and “Tattoo Goo.” Five recommended “dry healing,” which is an alternative method of healing that uses no ointments or creams. One participant recommended dry healing only for clients with sensitive skin, and another participant recommended the practice for the first day only. Interestingly, seven participants recommended using A&D ointment, but many of the other participants rejected the use of this ointment. Less than a third of the participants specifically stated how many times to apply the moisture method with eight recommending two to three times a day, one participant recommending six times a day, and one stating a nonspecific “several times a day.”
Sources of Knowledge
Overwhelmingly, the sources of knowledge for the participants were other artists and trial and error. Thirty-one percent stated their knowledge was passed to them from other artists outside their apprenticeship. This includes word of mouth and industry magazines. Another 22% referenced trial and error on their clients as their way of knowing good aftercare practice compared with 29% of the participants who described trial and error on tattoos on their own bodies. Only one participant stated that his or her knowledge came from a health class taken for tattoo artist licensing from the health department. Finally, two participants described that their knowledge was based on research but were unable to reference any specific source or articles.
Many participants changed their aftercare method after their time as an apprentice. Only three participants reported that they use the same method they learned in their apprenticeship. Most participants moved away from the A&D-type ointment toward a petroleum-based ointment and unscented lotions. Reasons for changing their aftercare method included liking another product through trial and error (31%), the product causing problems with a tattoo including losing color and skin reactions (34%), and an effort to reduce complexity in the instructions given to clients (13%). Nineteen percent of the participants did not describe any past methods and stated they have never changed their methods of aftercare.
Of the 32 participants, 28 provided verbal and written instructions to their clients describing tattoo aftercare, with one who also referred clients to a Web site. Four of the participants give only verbal instructions to their clients after the tattoo is applied. Giving only verbal instructions forces clients to remember days later how to care for their wounds. One participant stated he knew there were better care routines than the one he suggests, but he found that, if the routine was too complex, his customers would not follow the instructions at all. Only three participants specifically told clients to wash their hands before touching their tattoo to apply moisture or wash the wound.
The results of this research study indicate that the most common recommended tattoo aftercare methods include the use of antibacterial soap to wash the tattoo, leaving the tattoo open to air with no dressing, and the use of petroleum-based ointment or unscented lotion to moisturize the tattoo two to three times a day. Because of a lack of literature or research on tattoo aftercare methods, these methods cannot be identified as being the best possible practice for an industry standard, but instead, these are the most common methods described by participants in this study.
The research also revealed several issues concerning the quality of aftercare instructions. Most of the instructions lacked specifics on how often to wash and moisturize the wound. Vague instructions about how to do wound care leaves the client vulnerable to infection. In addition to this issue, many of the participants provided only verbal instructions to their clients. This practice forces clients to remember instructions hours and days later.
Although they are experts in their field, it is also a concern that the primary source of the participants’ knowledge was trial and error and word of mouth from other artists in the development of aftercare methods. Ways of knowing refers to how one acquires knowledge about the world and develops a relationship with surroundings. In this study, the knowledge base of the participants in this study was empirical because the methods were based on quantitative evaluation. One artist could have hundreds of observations of tattoo healing, but no artists reported keeping records or quantitatively comparing methods. One could also argue that there was a personal acquisition of knowledge in the way the artists began to understand the aftercare because the changes in their methods were a result of personal experience through the artists’ perspective.
It is important to note that most participants stated they experienced problems with products and reactions such as irritation and allergies and reported in this study that they had changed methods based on these reactions. These issues are largely undocumented in the research literature.