Nontuberculous mycobacteria skin infections associated with tattoos

Nontuberculous mycobacteria (NTM) skin infections associated with tattoos and permanent makeup (PMU) have emerged as an important public health concern alongside the growing popularity of these procedures. Since the first reported case in 2003, increasing numbers have been documented worldwide. To better understand their epidemiology and clinical characteristics, we conducted a review of published cases. As of December 2024, 62 articles described 66 tattoo-related NTM skin infection cases, involving 310 individuals across 15 countries. Notably, 25 cases were outbreaks, accounting for 262 affected individuals, with the first in 2005 linked to contamination of a gray tattoo ink bottle. Ten NTM species were identified, most commonly Mycobacterium chelonae (32 cases), followed by M. abscessus (12 cases), and M. haemophilum and M. fortuitum (4 cases each). Contaminated tattoo ink, either diluted with nonsterile water during procedures or contaminated during manufacturing, was the primary source of infection; poor hygiene also contributed. Cutaneous symptoms typically appeared within weeks of tattooing, yet diagnostic delays were common due to nonspecific clinical presentations. Microbiological culture and molecular methods were the primary diagnostic tools. Treatment most often involved macrolide-based combination antibiotic therapy for extended periods, typically 3-6 months; surgical intervention was performed in some cases. Four cases were associated with PMU, emphasizing that infection risk extends beyond traditional tattooing. Collectively, these findings highlight the need for stricter infection control measures in tattoo practice, regulatory oversight of ink production, and increased clinical awareness to promote early diagnosis and effective management of tattoo-related NTM infections.