Causes, patterns, and epidemiology of tattoo-associated infections since 1820

Despite increased awareness and public health initiatives, the incidence of microbial infections related to tattoos has increased since 2000. Building on the first paper in this two-part Series, which detailed the microbiological aspects of tattoo-related infections over the past two centuries from 1820 to 2023, this second paper describes the patterns, causes, and other related epidemiological factors of these infections. Since 2000, bacterial outbreaks, particularly those caused by non-tuberculous mycobacteria, have increased, prompting a re-evaluation of tattoos as a serious public health risk. Insufficient hygiene practices have been the primary cause of microbial infections, with contaminated tattoo inks also contributing substantially, leading to 11 outbreaks and subsequent ink recalls. Although rare, the tattooing process can occasionally lead to life-threatening infections and fatalities. Tattoos by both professional and non-professional artists were associated with infections, suggesting that regulated environments do not necessarily eliminate risk. Additionally, individuals with compromised immune systems, especially those with HIV, were particularly vulnerable to infections such as Leishmania. Although permanent make-up is often perceived as safer than conventional tattoos, infections still occur, with 11 cases reported since 2010. Furthermore, polymicrobial infections involving multiple pathogens have posed challenges for diagnosis and treatment. Overall, these insights highlight the historical and emerging patterns of tattoo-related infections and can inform the development of more effective public health guidelines, enhance preventive measures, and guide future research on reducing the risks associated with tattoos.