Tattoos reveal the most secret self history, epidemiology, health risks and complications
- Ottobre 16, 2023
- Pubblicato da: admin
- Categoria: Uncategorized
Psychologist, psychotherapist, anthropologist, PhD.
Adjunct professor at the “G. D’Annunzio” University.
Abstract: In recent decades, there has been a progressive increase in the spread of tattooing practice considered, at present, a form of body art that involves both women and men and especially young people. The application of tattooing consists in the injection of colored inks into the dermis which, remaining for a relatively long period of time, implies long-term exposure to chemical compounds and their degradation products. Consequently, this practice can in fact involve the risk of developing numerous infectious and immune side effects.
Tattooing is an ancient practice of which testimonies dating back over 5,000 years have been received. During this long period of time, techniques and procedures have evolved, but above all the motivations that lead people to trace indelible marks on their bodies have profoundly changed. In the past, this practice of permanent “writing” was used exclusively as a sign of distinction and belonging, for example, to a social caste or to an ethnic or religious group. Today, tattooing has lost its ancient meanings and has become an artistic and costume phenomenon. The so-called “Body Art” that uses body decoration as a form of artistic expression is in vogue and being such a widespread practice, has even become a consumer good with significant economic implications.
It follows that, with the growing “aesthetic” interest, the “health” interest in tattoos is growing more and more due to the awareness that this practice can produce serious undesirable effects.
The alarm comes mainly from dermatologists but also from official bodies for health protection that highlight the emergence of new health risks. The practice of tattooing, in fact, can carry the risk of serious inflammatory, immune, and infectious adverse reactions. Specifically, infections, mainly due to ink as the main source of contamination, can be particularly dangerous as they are sustained by antibiotic-resistant strains.
In addition, tattoo removal treatments that are increasingly in demand today can further increase the risk of adverse effects. For these reasons, it is necessary the joint action of doctors and decision-makers who issue national and international regulations relating to inks, to contribute to the protection and safety of people who choose to get tattooed.
1. Tattoo culture: Historical and anthropological notes
The term tattoo is of Tahitian derivation (from tatau = engraving, decorating the skin). It consists in the permanent coloring of parts of the body, either through the introduction or intradermal subcutaneous penetration of pigments of different colors by means of needles or various cutting edges, and with scarification techniques, to obtain indelible figures and drawings.
In the various cultural traditions, the human being has always been driven by the strong desire to elaborate a precise code of belonging and self-image that would constitute an element of distinction. In ancient times, this need was identified with the need to label the individual as a member of a given tribe, dragging with it religious, spiritual, and magical elements.
The practice of tattooing falls into the broader categories of “body art” and “body modification”. It represents one of the oldest forms of body art as evidenced by many archaeological finds.
The first examples of human beings known to us, of very recent discovery, are two Egyptian natural mummies found in the Nile valley attributable to predynastic Egypt, or between 4000 and 3100 BC. The mummies have two unique peculiarities: one of the two belongs to a man (probably a priest) and both bears fairly complex tattoos such as series of “S” and animal figures.
Prior to the discovery of Egyptian mummies, the oldest example of a tattooed human was the mummy of the Similaun, (Copper Age, about 5300 years ago), found on September 19, 1991, in the Ötztal Alps, which has been given the name of Ötzi. The mummy had 61 tattoos divided into 19 groups of lines whose purpose was not aesthetic, but therapeutic. It was discovered that the man suffered from arthritis and other musculoskeletal diseases and that tattoos, placed in painful areas and used as acupuncture, were used to relieve the pain caused by the diseases he suffered.
Tattoos of a magical nature – ritual, were found on the mummy of an Egyptian priestess with the appearance of a cow. Complex patterns such as lotus flowers, cows and monkeys cover their necks, shoulders, and backs. The most recurring design is the Eye of Horus, considered the most powerful of the talismans against malefics.
Through the centuries and cultures, the practice of tattooing has had alternating fates. Among the ancient Jews tattoos were forbidden, and by law, they are formally still today (the Torah forbids in the strict sense the irreversible tattoo, engraved on the skin), on the contrary they were in common use among the Celtic populations who for devotion to animal gods tattooed the bull, the wild boar, the cat, birds, and fish. Among the ancient Romans, tattoos were reserved for slaves and criminals; after contact with the Celts, the legionaries began to tattoo the initials SPQR (Senatvs PopvlvsQue Romanvs) associated with the legion of belonging as a sign of loyalty to Rome.
During the Middle Ages, the Renaissance and much of the Modern Age, the practice of tattooing disappeared as a mass phenomenon, remaining linked to religious, criminal, marine, military and guild of arts and crafts.
At the beginning of the 1700s, the tattoo came back into vogue when European sailors met the indigenous populations of the Pacific islands, where tattoos had a positive cultural value such as to be proudly flaunted because they often corresponded to a privileged social and political status, so much so that in New Zealand the Maori signed their treaties drawing faithful replicas of their “moko” or personalized facial tattoos.
In China, the practice of tattooing was born to distinguish the members of the various criminal associations and their role in them. Generally, ideograms were tattooed “institutionally” on slaves and criminals.
In Japan the testimonies of the practice of body decoration date back to the fifth century BC, also in this case linked to magical, aesthetic, or criminal identification purposes. In this country the tattoo was also used as a weapon of social rebellion as those who did not belong to the upper ranks of society were forbidden to use the kimono therefore choosing to decorate their skin in protest.
Among some populations such as the Samoans, the methods used to inject color into the dermis included the use of sharp objects or coarse needles that made the practice so painful as to be considered a test of strength and courage linked to initiation rituals. In reference to this, in 1981 the New Yorker Samuel O’Reilly patented the first electric tattoo machine with a considerable reduction in pain.
In the culture of the nineteenth and twentieth centuries tattoos were considered “socially unacceptable” (although in vogue among the nobles) so much so that Adolf Loos, considered one of the first modern architects, in his book “Ornament and crime” declared that: “There are prisons where eighty percent of prisoners are tattooed. As a result, tattooed individuals who are not in prison are considered latent delinquents or degenerate aristocrats. If it happens that a tattooed man dies in freedom, it simply means that he died a few years before he could commit his crime.” In this period tattooing was still associated with underworld environments, mental illness and moral disorder.
With the development of the counterculture, between the 60s and the 80s of the twentieth century, this negative vision was overcome when the tattoo became an expression of social rebellion and anger on the part of some groups of young people such as Hippies, Punks and Bikers who opposed the common morality.
Finally, a substantial reversal of the trend occurred between the late 80s and early 90s of the twentieth century when the practice of tattooing turned into a celebration of one’s way of being that generated a real fashion, in which the tattoo became a manifesto of personal life events that consecrates the victory of hedonism over the body.
2.Tattoo psychology: the psychological meaning of tattoos
The “psychology of tattooing” was born with the aim of studying the character of people based on the marks indelibly imprinted on their skin. According to this interpretation, depending on the area there are some psychological nuances.
- Tattooing the left side of the body, which for psychoanalysis represents the past, is typical of negative, disheartened people.
- The right side is linked to the future and denotes a positive character, open to change.
- Tattooing the trunk denotes concreteness and decision-making skills
- Tattooing your arms indicates that the person is going through a maturation phase. – Tattooing the legs indicates that the person is not very reflective and childish
- The ankle is the area preferred by suspicious and jealous women, but also very feminine and competitive and combative men
So, when it comes to our body, the meaning of symbols cannot be interpreted with simple intuition but sought in the unconscious. The choice of design and the area to be tattooed is never neutral but refers to the world of symbols and brings out what is hidden within the individual, his true character.
The psychological reasons behind a tattoo can be among the most disparate: it can have religious, political, spiritual, transgressive meanings. Nevertheless, those who get tattoos hide very specific motivations within themselves:
- Search for one’s own identity: for those who feel lost in the world, for those who do not recognize themselves in any social and cultural stereotype, the tattoo is a symbol of identity recognition. Thanks to a mark on the skin, one finds one’s ego and consequently one’s place in the world. It can also demonstrate a sign of change for those who feel suffocated in monotony, a gesture that represents a sign of transformation.
- A message for others: the body becomes a canvas on which to paint; we get tattooed to communicate to others our moods or more simply our thought that goes against the current. It is a message that can take colorful and romantic forms but also violent and rebellious.
- A rite of passage: for many boys, especially teenagers, tattooing can take on the meaning of a ritual. A moment of passage in which, to exorcise a particular pain, we get tattooed demonstrating strength and courage. A way to feel less alone and be accepted by those around us.
In any case, the deepest reason that pushes an individual to get tattooed, in fact, is precisely that need to stand out from others, the need to visually affirm their diversity.
The tattoo, therefore, brings out something that we generally tend to hide from others and keep to ourselves. Branding the skin is not pure ornament but is instead linked to the mechanisms of self-definition.
2.1 Identity, identification, body image and tattoo
Nowadays tattooing has become a mass phenomenon as it involves people of any age and social class, and for this reason it has lost, although not completely, its transgressive and nonconformist connotation.
The writer Stefano Pica in his book Tattoo & Psyche explains that identity, identification, and body image are psychic dimensions that revolve around the practice of tattooing.
Your body and your instincts indicate the starting point of identification and are understood as phenomena of accommodation of the organism with respect to an environment in activity and change. It means changing environment everything related to the cultural complex that is knowledge, beliefs, art, oral, customs, laws and so on. Identification is therefore the mechanism that allows adaptation to any culture and consequently is decisive for the realization of the tattoo, as a cultural product. Culture exerts a very strong influence in the practice of tattooing; It is no coincidence that there are tribal societies in which this function is practiced as a social custom; The sense of belonging to a given culture is based on the sharing of symbolic aspects and social practices that contribute to building in an individual his body image and his identity.
In his book Stefano Pica later states that the tattoo is placed in the continuum between the body image and its mental representation. The body, in fact, is the vehicle of our being in the world for which it undergoes every form of change both about environmental circumstances and those internal to the individual, and also on it desires and aspirations are projected by us; Sometimes, however, it happens that the body image does not correspond to his mental health, therefore, we will try to change it. It is precisely in this passage that, according to Pica, the tattoo comes into play as a modifying agent, placing itself in the manner of a possible stabilizer of subjectivity.
In summary, the author places as the most important motivational bases that induce the practice of tattooing the internal needs of the subject to resolve a conflict between body image and his body ideal
2.2 Functions of the tattoo
Basaglia states: “One cannot speak of man without being sent back to his corporeality [… ]. Our entry into the world takes place in fact in the moment of our appearance as a body: every expression, every attitude with which man gives himself and grasps the world is body [… ] The identity of our birth and death is still a body.”
For some, tattooing or piercing is a form of self-expression, it can symbolize the desire to remember an important event or experience in life, for example for American military cadets it is a rite of passage. Other research has suggested that psychosocial stressors, such as exposure to trauma, may be associated with the recurrence of bodily modifications.
The tattoo contains several functions:
Exorcist: In the past it was used to exorcise the fear of death (the ritual of physical pain simulates the passage from life to death). Today, however, you can resort to tattooing to exorcise phobic problems.
Psychotherapeutic: tattooing can have a healing purpose. You can have the belief that by acting on the body you have a modification of the mind. Jeffreys (2000) and Martin (1997) state that women who are victims of trauma such as sexual abuse often resort to mutilation. Victims of sexual abuse show significantly lower self-esteem and have a greater number of tattoos (Reyntijens, 2002). At the same time, however, abused women who have many tattoos have a level of self-esteem equal to that of subjects without a history of abuse, which can be interpreted as a therapeutic use of the tattoo. It is as if women who have been abused are trying to reclaim their bodies by indelibly marking them.
Communicative: the tattoo takes on an affective function, describes the bonds that want to be lasting and indelible like the tattoo itself.
Aesthetics: the tattoo is used to beautify the body, cover scars and blemishes as an alternative to aesthetic medicine (eg. With plastic surgery the mouth can become larger; the tattoo can widen the contour or mark the red line as permanent makeup).
Social: Tattoo as a need to belong to a group.
.2.3 Psychological model: pain and blood in tattoo practice
Pleasure and pain represent the basic affective stages of the experiences of living beings; In this case, psychologists speak of experiences placed on the pleasure-pain axis.
The role of pleasure and pain in tattooing assumes great importance; It is generally known that the act of piercing the skin induces a state of suffering for the body as it induces pain and therefore places it in an unpleasant position. Based on what has been explained, it emerges that in the path that leads to the tattoo there are elements related to masochistic fantasy. The masochistic aspect in the act of tattooing can be explained by the psychological model.
By psychological model we mean an identification with the parental model: it is well known that from birth unconscious processes of identification are initiated towards one’s parents and slowly also towards other people who surround childhood life. It can happen, however, that sometimes the paternal or maternal model can be unattainable, attracting strong anxieties in the child. The parental figure, thus, is experienced in a castrating way due to its inaccessibility and this would stimulate behaviors opposite to those suggested by the parental model, to affirm one’s diversity.
This rejection of the parental model is generally accompanied by guilt that shows itself with painful feelings, such as the feeling of not being worth anything.
All this would explain why the tattoo has spread, initially precisely in the so-called deviant cultures, becoming the symbol of the rejection of a rule experienced as castrated.
Guilt and a disqualified idea of oneself find a momentary solution in the masochistic search for pain. Moreover, with the “desecration of one’s own body through the tattoo we want to deny the parental model, since we go to “dirty” the body given to us by our parents, creating a new image of oneself that would serve to fill the “abidicata identity” with parental rejection.
2.4 When can we talk about psychopathology?
One can speak of psychopathology when the modification of the body is perceived as necessary and pressing. In these cases, we can postulate that behind the symptom hides a body image disorder whose extreme form is body dysmorphism. Body Dysmorphism is the distressing and persistent preoccupation with a defect in physical appearance. The defect can be imaginary, or, if a small physical abnormality is present, the subject’s concern is far excessive.
Most individuals with this disorder experience severe discomfort from their supposed deformity, describing theirconcerns as “intensely painful,” “tormenting,” or “devastating.” In addition, they find their worries difficult to control, and they make little or no attempt to resist them. This disorder can lead the subject to repetitive behaviors or frequent control of the defect or, directly or in a reflective surface e.g., mirrors, shop windows, watch glasses… With this behavior there is the intent to control and involves a decrease in anxiety.
The data available in the literature indicate that the most common age of onset of this disorder is between 15 and 20 years and that women are somehow more frequently affected than men.
In this regard, a longitudinal study conducted by Roberts and Ryan (2005) on a sample of 6072 adolescents, notes the presence of tattoos in 4.5% of the sample and a significant association between being tattooed and drug use, school problems and increased sexual activity. It has also been found that subjects with tattoos and / or piercings are more impulsive and show a greater tendency towards the search for sensations (Stirn, Hinz and Brahler, 2005).
Regarding the presence of psychological distress, the study highlights that:
- With respect to the relationship with one’s own body, the results obtained show in the research group, a greater concern with respect to one’s body image. Specifically, these concerns concern the morbid fear of weight gain, compulsive control of physical appearance and the urge to thinness. These results seem to confirm a study by Carrol and Anderson (2002), which finds in subjects who resort to BM practices, negative feelings, and feelings about their body.
- Significantly high scores, for the research group, on the scales of anxiety and somatic symptoms. These data confirm those obtained by Stirn et al (2005) in whose study subjects using BM practices were found to have higher scores on GHQ scales.
- Finally, for the research group, a more frequent tendency to implement some self-injurious behaviors, such as getting wounds, emerge.
3. Health risks and complications associated with tattooing Possible health risks related to tattooing may include:
- From microbiological contamination
- From the presence of hazardous chemicals in inks
- From the procedures themselves, when they are not carried out by trained professionals in adequate hygienic conditions and in suitable facilities.
With the tattoo procedure, the skin barrier is damaged, and the wound can be prone to infection, particularly if the appropriate hygiene recommendations are not respected.
Specifically, adverse effects can be divided into the following categories:
- Bacterial infections: papules, superficial skin pustules, folliculitis, furunculosis, systemic infections with associated gangrene, osteomyelitis, epidural abscesses, septicemia, and toxic shock syndrome.
- Viral infections: Molluscum contagiosum and Papilloma Virus (HPV), Hepatitis B, C and HIV infection. 3) Acute aseptic inflammations: pain, redness, blisters, swelling, itching, erythema, mild bleeding during the healing process, lymphatic edema, and regional lymphadenopathy. 4) Allergic hypersensitivity or autoimmune reactions including:
- Allergic reactions: eczematous dermatitis, photosensitization, granulomatosis, pseudoepitheliomatous hyperplasia.
- Underlying dermatoses reactivated by tattoo: Koebner’s phenomenon, sarcoidosis, vasculitis.
Other effects that can be found are:
- Pigmentation disorders
- Nerve injury resulting in altered sensation or local motor skills
4. Epidemiology In Italy
Statistical data on tattoos in Italy are the result of a survey conducted in 2015 by the Istituto Superiore di Sanità (ISS), in collaboration with IPR marketing (Independent Institute Specialized in market research and analysis), on a sample of almost 8,000 people representatives of the Italian population aged twelve and over.
In Italy there are an estimated 7 million tattooed people or 12.8% of the Italian population, a percentage that rises to 13.2% if we also consider the ex-tattooed.
The study shows that:
- Those who get tattooed do it mainly for a hedonistic choice or tattoo as decoration and ornament of the body,
- 0.5% of the population undergoes tattoos for medical purposes (for example, tattooing of the nipple-areola complex or endoscopic tattooing),
- 3% for aesthetic purposes (the so-called permanent makeup).
In addition, the survey reports that:
- 76.1% of tattooed people went to a specialized center,
- 9.1% of tattooed people went to a beauty center,
- 13.4% did so outside the authorized centers and this can constitute a significant source of risk.
Characteristics of the population
Tattoos were more common among women surveyed than men (13.8% women vs. 11.7% men). The first tattoo is carried out on average at 25 years; but the largest number of tattooed is in the age group between 35 and 44 years (29.9%); while among minors (12-17 years) the percentage is equal to 7.7%.
Gender differences emerge with respect to the tattoo site as men prefer to tattoo arms, shoulders, and legs while women especially the back, feet and ankles. Most people say they are satisfied with the tattoo (92%), however as many as 17.2% said they wanted to remove it: of these, 4.3% have already done so.
Finally, it is reported that 3.3% of tattooed people claim to have had complications or reactions, but the figure appears underestimated. Among the most frequent complications are pain, granulomas, thickening of the skin, allergic reactions, infections and pus. In all these cases only 12.1% went to a dermatologist, 9.2% to the family doctor, 27.4% went to their tattoo artist and more than half (51.3%) did not consult any of these professionals.
In general, only 58.2% of respondents are informed about the risks: the perception of the risks considered most frequent concerns: allergic reactions (79.2%), hepatitis (68.8%) and herpes (37.4%) while only 41.7% are adequately informed about contraindications.
Considering the above, it is therefore possible to affirm that the knowledge of the population in terms of safety, contraindications and complications associated with the practice of tattooing, appears globally insufficient. Therefore, there is a need for better information on the subject and greater awareness of the risks of infectious and non-infectious diseases.
The 2016 Joint Research Centre (JRC) report “Safety of tattoos and permanent make-up: Final Report” estimates that there are over 60 million tattooed people in Europe, or about 12% of the population.
In addition, in the report of the European Chemical Agency where it talks about the trend lines for the future, scenarios are described, and estimates are provided on the number of tattooed people expected for 2040. In the main scenario, the growth trend is assumed to remain similar to that observed between 2003 and 2014, when the estimated number of people with at least one tattoo rose from almost 30 million people (2003) to over 62 million (2014).
In this hypothesis, using data processed on the basis of Eurostat demographic projections and the work of the Joint Research Centre, the report estimates that by 2040 the population of people with at least one tattoo could double, with a prevalence rate of 26.1%. Conclusions
This work has as its fundamental objective to briefly illustrate the birth, the current knowledge on the state of the art, the psychological meaning and motivations that push the individual to tattoo and, finally, the main sources of health risk related to the practice of tattooing.
Consequently, in light of the above, it emerged that the practice of tattooing was already present in prehistoric populations, initially linked to magical-therapeutic rituals. It is possible to observe some examples on partially intact bodies such as the mummy of the man of the Similaun glacier (or Ötzi), found in 1991 and dating back to 3300-3100 BC. This mummy had 61 tattoos consisting of simple dots, lines and crosses positioned at the joints and back where the presence of osteoarthritis was found by researchers; Those tattoos could be linked to a prehistoric form of acupuncture done with medicinal herbs, in order to heal or relieve the joint disorder.
Subsequently, the practice of tattooing has also developed in the great ancient civilizations, such as the Egyptian, of ancient Rome, and, over time, has spread to different parts of the world (Japan, Oceania, China, Africa and Polynesia), with different symbols and meanings depending on the period and place.
In addition to purely aesthetic reasons, in the past, among the main motivations behind a tattoo emerge: tattoo as a sign of belonging to a group (social, religious, ethnic), for apotropaic purposes (to protect oneself from malignant influences, diseases), to prepare for the afterlife, to define gender differences or social rank as in the Maori civilization, as a stigmatizing “brand” (for slaves, criminals etc..) or as a form of transgression.
Currently, tattooing has taken on the value of a fashion phenomenon, socially accepted: tattoo as decoration, body ornament.
With regard to possible health risks, it has been highlighted that they can be generated by microbiological contamination, the presence of dangerous chemicals in inks or the procedures themselves, in particular when they are not performed under adequate hygienic conditions and by trained professionals. Therefore, it is essential that, in addition to respecting the health and safety standards relating to the work environment, maximum attention is paid to the methods of execution and the safety of the materials and colors used, as well as to the preparation, experience and skill of the tattoo artist.
Since the application of a tattoo requires in fact the rupture of the integrity offered by the skin barrier, the procedure is inevitably linked to the exposure of health risks, including allergic reactions and other complications, in addition to the more or less strong pain perceived during the drawing. Tattoo adverse reactions may begin early, immediately after the procedure, or may occur later even months and years later. Among the risks to be evaluated are: allergic reactions, infectious diseases (which occur if the equipment used to make the tattoo is contaminated with infected blood), skin infections (redness, swelling and pain), granulomas, scars, keloids and complications during magnetic resonance imaging, i.e. in rare cases patients report swelling and burning on the tattoo following magnetic resonance imaging. In addition, it has been found that tattooing may have a potential role in carcinogenesis, therefore, this reality cannot be overlooked by health services. In particular, awareness should be increased in practitioners and users that tattooing, in addition to being an art form, involves internal exposure and a mix of ingredients that have not been characterised in relation to possible adverse health effects.
From an epidemiological point of view, currently the surveys carried out in Italy show that in the face of a large diffusion of tattooing, the relative knowledge is scarce and inadequate. Consequently, it is necessary to intervene promptly to inform users and operators. International consumer protection measures and harmonised scenarios for ink risk assessment are also needed to support health interventions.
Finally, it must be considered that the complications of tattooing affect the general health conditions and also the psycho-social sphere of the individual; For these reasons it is therefore necessary to plan effective communication and health promotion strategies dedicated especially to the youngest.
- Abiona TC, Balogun JA, Adefuye AS, Sloan PE. Bodyartpractices among immates. Implications for trasmission of Bloodborne infections. Am J Infect Control 2010;38(2):273-86.
- Annex XV Restriction Report-Substances in tattoo inks and Permanent Make-up della European Chemical Agency (Echa).
- Breuener CC, Levine DA; AAP Committee on Adolescence. Adolescent and young adult tattoing, piercing, and scarification. Pediatrics 2017;140(4): e20171962.
- Bhardwaj SS, Brodell RT, Taylor JS. Red tattoo reactions. Contact Dermatitis 2003;48(4):236-7.
- Body, gaze and silence. The enigma of psychiatric subjectivity (1695).
- DSM- Diagnostic and Statistical Manual of Mental Disorders, AA VV. American Psychiatric Publishing, 2013, 5°edizione
- DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Edizione Italiana: Masson, Milano.
Under the skin. Psychoanalysis of bodily modifications. Lemma Alessandra. Publisher: Cortina Raffaello.
- Friedman R, Antoine D, Talamo S, Reimer PJ, Taylor JH, Wills B, Mannino MA. Natural mummies from Predynastic Egypt reveal the world’s earliest figural tattoos. J Archaeol Sci. 2018; 92:116-25.
- Gallè F, Mancusi C, Di Onofrio V, Visciano A, Alfano V, Mastronuzzi R, Guida M, Liguori G. Awareness of healthrisks related to body art practices among youth in Naples, Italy: a descriptive convenience sample study. BMC Probl Health 2011; 11:625.
- Gallè F, Quaranta A, Napoli C, Di Onofrio V, Alfano V, Montagna MT, Liguori G. Body art practices and healthrisks: young adults’knowlwdge in two regions of southern Italy. Ann Ig 2012;24(6):535-42.
- Gulati S, Jain A, Sattari M. Tattoing: a potential novel risk factor for iliopsoas abscess. World J Clin Cases 2014; 2(9):459-62.
- Hogsberg T, Saunte DM, Frimodt-Moller N, Serup J. Microbial Status and product labelling of 58 original tattoo inks. J Eur Acad Dermatol Venereol 2013; 27:73-8.
Islam PS, Chang C, Selmi C, Generali E, Huntley A, Teuber SS, Gershwin ME. Medical Complications of Tattoos: A Comprehensive Review. Clin Rev Allergy Immunol 2016;50(2):273-86.
- Juhas E, English JC 3rd. Tattoo-associatedcomplications. J Pediatr Adolesc Gynecol 2013;26(2):125-9.
- Khunger N, Molpariya A, Khunger A. Complications of tattoos and tattoo removal: stop and think before you ink. J Cutan Aeshet Surg 2015; 8(1):30-6.
- Kluger N. Epidemiology of tattoos in industrialized countries. Curr Probl Dermatol 2015; 48:6-20.
- Kluger N. Cutaneous and systemic complications associated with tattooing. Presse Med 2016; 45 (6Pt1):567-76.
- Kluger N, Koljonen V. Tattoos, inks, and cancer. Lancet Oncol 2012;13(4):161-89.
- Kean WF, Tocchio S, Kean M, Rainsford KD. The musculosketal abnormalities of the Similaun Iceman (ÖTZI): clues to chronic pain and possible treatments. Inflammopharmacology 2013;21(1):11-20.
- Le Blanc PM, Hollinger KA, klonz KC. Tatoo ink-related infections. Awareness diagnosis, Reporting and prevention. N Engl J Med 2012; 367:98-7.
- Laux P, Tralau T, Tentschert J, Blume A, Al Dahouk S, Bäumler W, Bernstein E, Bocca, B, Alimonti A, Colebrook H, de Cuyper C, Dähne L, Hauri U, Howard PC, Janssen P, Katz L, Klitzman B, Kluger N, Krutak L, Platzek T, Scott-Lang V, Serup J, Teubner W, Schreiver I, Wilkniβ E, Luch A. A medical-toxicological view of tattooing. Lancet 2016; 387:395-402.
- Majori S, Busana M, Baldo V, Collaborative Group. Piercing and tattoing in high school students of Veneto region: prevalence and perception of infectious related risk. J Prev Med Hyg. 2013;54(1):17-23.
- Palmieri A. Tattoo. From the origins to the present day. Mass: Eclectic;2011.
- Tattoo psycholgia of M. Cannavicci.
- Serup J, Carlsen KH, Sepehri M. Tattoo complaints and complications: diagnosis and clinical spectrum. Curr Probl Dermatol 2015; 48:48-60.
- Schreiver I, Hesse B, Seim C, Castillo-Michel H, Villanova J, Laux P, Dreiack N, Penning R, Tucoulou R, Cotte M, Luch A. A Synchrotron-based v-XRF mapping and µ-FTIR microscopy enable to look into the fate and effects of tattoo pigments in human skin. Sci Rep 2017;7(1):11395.
- Simunovic C, Shinohara MM. Complications of decorative tattoos: recognition and management. J Clin Dermatol 2014;15(6):525-36.
- “Safety of tattoos and permanent make-up. Final Report “Publications Office of the European Union; 2016. DOI: 10.2788/011817.
- Samadelli M, Melis M, Miccoli M, Vigl EE, Zink AR. Complete mapping of the tattoos of the 5300-yearold Tyrolean Iceman. J Cult Herit 2015, 16(5):753-8.
- Tatutori.it. History of tattooing. 2016. Available at: https://www.tatuatori.it/storia-tattoo; last consulted 22/02/2018.
- “The tattooed population in Italy: national survey on demography, characteristics and perception of health risks” Ann Ist Super Sanità 2018, Vol 54, No. 2: 126-136.
- Velez L, Harb J, Anuszewski S, Wesson S. Cutaneous Mycobacterium massiliense infection from tattoing: a common yet under-reported and persistent epidemic hazard for dermatologists. BMJ CASE Rep 2018;12;2018.
- Watson T. Intricate animal and flower tattoos found on Egyptian mummy. Nature 2016;533(7602):155.
- Wenzel SM, Rittmann I, Landthaler M, Baumler W. Adverse reactions after tattoing. review of the literature and comparison to results of a survey. Dermatology 2013;226(2):138-47.
- Wollina U. Severe adverse events to tattoing: an retrospective analysis of 11 years. Indian J Dermatol 2012;7(6)439-43.
- Montelli A. (2014). The psychological meaning of tattoos. http://www.donnamoderna.com/salute/significatopsicologico-dei-tatuaggi#dm2013-su-titolo