If you have arthritis you should think carefully before having a tattoo. Dr. John Ioannou explains why
It’s the decade of self-expression. Most of us now own smart phones and we’ve taken to photographing and recording our life experiences – on Instagram, Twitter, Facebook and personal blogs – with fervour. We can’t help ourselves from sharing with the world a little more of who we are, as artfully as we can.
Tattoos are part of this story; as a form of creative self-expression and identity marking, body art is now so accepted, celebrated and even expected by young people that it’s hard to spot the 20-something girl or guy at a party without a tattoo.
So, if you’re between 18 and 40 it’s not unlikely that you’ve thought of having a tattoo yourself. There are plenty of beautifully adorned folk out there to tempt you, and who doesn’t love a tattoo Pinterest board? But, can you have a tattoo if you have arthritis?
We put that question to Dr. John Ioannou (PhD FRCP), Reader and Honorary Consultant in Adolescent and Adult Rheumatology at University College London Hospitals and Great Ormond Street Hospital. His short answer is yes, you can have a tattoo if you have arthritis, though he doesn’t generally advise it because the risks will be more significant for you than for a person without an inflammatory disease. Below, Dr. Ioannou answers our specific questions in full.
But first, what is a tattoo?
A tattoo is made by the injection of ink under the skin by a needle, which in effect creates a wound, which needs to heal. It is essential that the procedure is sterile and there is good aftercare during the healing stage. It’s crucial to have a tattoo at a reputable place that has been inspected and licensed – your local authority should keep a list of licensed salons. We called one local authority in London as a test, and they duly emailed us a list within 24 hours.
What are the general risks?
There are a number of risks for anybody having a tattoo. These include skin infections, transmission of blood borne infections including tetanus, hepatitis B and C, and even HIV, allergic reaction to the inks, and long-term sensitivity. There is also the risk of developing granulomas around the tattoo (small lumps under the skin) and noticeable scarring, especially if you have an infection.
These risks are slim, especially if you go to a reputable salon and take good care of your tattoo afterwards, and it’s understandable that many of you will accept these risks and want to have a tattoo.
An expert opinion
Dr. John Ioannou (PhD FRCP), Reader and Honorary Consultant in Adolescent and Adult Rheumatology at University College London Hospitals and Great Ormond Street Hospital, explains the additional risks to you as a person with arthritis, so that you can make an informed decision about whether to go ahead:
Arthur’s Place: There are a number of risks associated with having a tattoo for all people, which we list below. For somebody with arthritis, how might his or her risk compare with regard to:
Dr. Ioannou: It depends on what treatments you are on. Just having arthritis doesn’t increase the risk of having an infection, but some of the treatments can increase the risk.
Treatments that suppress the immune system, for example biologics, in theory cause an increased risk of infection. Examples of biologics are drugs such as Enbrel, Humira, Rituximab, Tocilizumab and Orencia. Methotrexate and steroid medications also suppress the immune system.
Not all arthritis medications suppress the immune system, though. Hydroxychloroquine is not deemed to be an immune-system suppressant. Anti-inflammatories like Nurofen, which are effectively painkillers, don’t suppress the immune system either, or cause any problems with healing.
To be certain, I would flag it up with your rheumatologist or GP, and ask: “Am I on a treatment which suppresses my immune system?” If you are on such a drug, and you do decide to go ahead you will need to pay extra special attention that the procedure is sterile and with the aftercare, in terms of making sure the site is kept clean and so forth.
Could it be more serious if they do contract infection?
Dr. Ioannou: There is no medical evidence to prove this, as in no studies have been done, but if a patient was on a drug which suppresses the immune system and had an infection after having a tattoo, in theory they may have a higher chance of the infection being more serious.
This is based on what we know of what these drugs do. In theory it might cause more severe problems in terms of more inflammation or taking longer to heal, therefore needing more active treatment.
Being on these drugs affects the potential severity of the infection because the immune system is not in theory strong enough to get rid of the infection quickly enough.
Dr. Ioannou: To my knowledge being allergic to tattooing inks or latex gloves (often worn by tattooists) is of no extra concern to arthritis sufferers compared to the general population. Being allergic to latex gloves in my experience affects patients with and without arthritis equally.
Sensitivity during MRI scans (some people have reported feeling a hot sensation on the site of a tattoo during MRI scans)?
Dr. Ioannou: Many young people with arthritis do have MRI scans. It’s often required, not by everybody with arthritis, but it does happen with increased frequency in this particular group.
In saying that, sensitivity during MRI scans is not something that I have seen reported to us. But in terms of do people with arthritis have more regular MRI scans, yes it would be an investigation that we do quite regularly in some patients.
Dr. Ioannou: The worse the inflammation from an infection, for example, the more chance there is of scarring afterwards. And there is an increased risk of contracting infection, or that infection becoming more serious, in people with a suppressed immune system.
Arthritis doesn’t suppress the immune system, but some drug treatments for arthritis do.
Dr. Ioannou: No, not really any issues. Granulomas do not happen more often in patients with arthritis who have tattoos.
Dr. Ioannou: If there is a joint that is particularly problematic, then doing a tattoo over that area may not be a good idea because in the future it’s possible that there will be a lot of inflammation to that joint or an operation might be needed.
An ankle is a good example. Ankle joints are often affected in many types of JIA and the ankle is a popular area for tattoos. Sometimes, in the future, an operation may be required to an ankle and the site of the scarring could vary depending on the type of operation.
If you do decide to have a tattoo, in general we do advise NOT to tattoo over a joint just in case that joint becomes problematic in the future. It may not need surgery but it may require an injection, and we don’t like to inject through a tattoo ideally.
Dr. Ioannou: If it’s a small tattoo that’s not normally an issue. For quite large tattoos there is a possibility that it could be a problem not to be able to see the natural skin colour if you have a type of arthritis that is associated with a rash. Systemic JIA often occurs with a rash, for example. It’s best to avoid parts of the body that are more likely to be affected, such as joints.
Arthur’s Place: The signs of infection are redness, swelling, pus or changes in skin colour. What should a person with arthritis do if they experience any of this?
Dr. Ioannou: If it’s just looking a bit red and not too serious then go to the GP within a day – you do need to be seen even if it’s not too serious. The GP can look at the area and decide if you need antibiotics and to give advice as to how best to care for the wound.
If the area is very red or swollen or if you have a fever you do need to go to a hospital casualty department if you can’t access your GP within 24 hours, because that would suggest quite a serious infection.
Dr. Ioannou: Yes. If relevant to you, you should mention that you are on drugs that could suppress your immune system and there is therefore an increased risk of infection. The tattooist may take extra care to make sure it is a sterile procedure.
It’s important to go to a place that is appropriately licensed, undertakes hygienic procedures and is a reputable place. You can ask for guidance for aftercare, and a properly licensed place will be able to give that advice. You should mention any allergies, too.
Dr. Ioannou: Yes. It is important because then the advice I’ve given here can be reinforced. Particularly the aftercare, making sure it’s clean, is well tended to, and acted upon quickly if there are any signs of infection.
Also, to talk through where the tattoo goes. I am really uncomfortable with having tattoos over joints incase the joint becomes a problem in the future. Just a joint becoming swollen can affect how a tattoo looks, let alone any surgery that might be required.
Arthur’s Place: Should any consideration be given to the timing of a tattoo and planned drug treatments?
Dr. Ioannou: Drug treatments are started as soon as we can to control the arthritis, because that is the priority. So, if the question is about delaying drug treatments around the tattoo we would not advise that because the quicker we get control of the arthritis the better the patient feels and the less damage occurs to the joint, which is important for preserving function in the future.
With regard to the timing of infusions and other regular treatment – if the drug is given by infusion or by a subcutaneous injection I would advise not to have a tattoo on the same day because if there is any reaction, such as a fever, it would be hard to know whether that is an unexpected reaction to the drug or the tattoo.
So, it would make sense to wait for a few days after having an infusion of a drug. It’s not such an issue with Methotrexate, but would be more of an issue with drugs that are given by intravenous infusion because that’s where we sometimes see a reaction to the drug.
Arthur’s Place: Are any drugs incompatible with tattooing, specifically around heightened skin sensitivity or pain thresholds?
Dr. Ioannou: Not to my knowledge.
Dr. Ioannou: Any type of surgery in patients on the kinds of drugs I mentioned earlier that suppress the immune system, in theory leaves them more prone to infection.
If a patient were undergoing surgery I would not advise having a tattoo because if there is an issue with that you’ll have multiple problems. Better to heal fully from the surgery before going on to have a tattoo.
Dr. Ioannou: We are very interested in the relationship between stress and flare-ups in young people. In terms of the issue of tattoos, if the person who is having it finds that a very stressful experience in theory there is the possibility that their threshold to flare-up will be lower. Having a tattoo itself, it’s unusual to cause the level of stress that will then predispose to a flare.
The more common reason we see flares is that young people wrongly stop their drug treatments a few weeks before having a tattoo. That would be misguided in our opinion. In those cases arthritis can flare, and if there is more inflammation in the body then it becomes more uncertain what will happen to their new tattoo.
Dr. Ioannou: With regards to the arthritis element everything above applies. With regards to psoriasis, I’m not a dermatologist, so it’s slightly out of my area of expertise. I am not aware that psoriasis flares or is different in patients with a tattoo.
But, a clinician would want to see the psoriasis, and if psoriasis did occur over the area of a tattoo it would affect the look adversely. It seems sensible to avoid having tattoos over areas where you tend to have psoriasis. Psoriasis can occur anywhere on the body and you can’t predict where. So there are particular risks.
Dr. Ioannou: With regard to age, the younger you are, if you are still growing, we advise not to have a tattoo because the shape of it will change as you grow. That’s common sense.
In terms of being older, typically it’s the more elderly population, 65-plus really, they would have an increased risk of contracting an infection, as you start to enter the age range where the immune system is weaker anyway. And if a person has arthritis that’s an added problem for the immune system.
Arthur’s Place: Laser removal breaks down ink pigment, which is disposed of by the body. The immune system has a part to play in making this happen. Are there any increased risks for people with arthritis?
Dr. Ioannou: There are no particular considerations to my knowledge, as to whether having arthritis or being on immune system-suppressant drugs affects the outcome of laser removal.