Hyperpigmentary Skin Conditions & Cosmetic Tattooing

by Andrea Darby - Master Medical Tattooist & Industry Educator
Post Inflammatory Hyper-Pigmentation

Clients/Patients who have darker skin tones may be more susceptible to a condition called Post Inflammatory Hyper-pigmentation or PIH for short. Clients who have or may develop PIH have hyperactive melanocyte cells in their skin.

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Some Cosmetic Tattooists routinely refuse to provide cosmetic tattooing services to clients/patients with darker skin tones due to the risk of hyper-pigmentation reactions which are often misconstrued as tattoo pigment changes by the tattooist.

We consider a blanket ban on cosmetic tattooing for clients/patients with darker skin tones to be inappropriate and it also has discriminatory connotations for the client/patient and ultimately may cause them distress.

We believe it is much better and more appropriate to educate the client/patient about the possible risks and exclude those clients/patients at greatest risk, and of course test patch to gauge the likely outcome.

Clients/Patients who have darker skin tones may be more susceptible to a condition called Post Inflammatory Hyper-pigmentation or PIH for short. Clients/patients who have or may develop PIH have hyperactive melanocyte cells in their skin and if their skin experiences any form of irritation their melanocyte cells may be stimulated to produce more melanin.

With PIH the tattooed skin may produce melanin and become darker in colour (grey, blue, brown or black) and the tattoo pigment may be patchy or may be hidden by the melanin completely and not be visible at all. Potentially a person from any ethnic background can have PIH but people with darker skin tones are more susceptible simply because they have more melanocyte cells that are more active and people from Africa, Asia, Latin, and indigenous Indian backgrounds are the most susceptible.

With PIH if melanin is deposited in the epidermis then sometimes the increased pigmentation (brown/black) will fade over time much like a sun tan can fade, but if the melanin is deposited into the dermis (grey/blue) then it may remain darker in colour permanently, mixed deposits in the epidermis and the dermis (brown/grey) may lighten a little over time but will likely mostly remain visible.

The depth of melanin within the skin will appear to change the colour of the melanin due to the Tyndall effect, you can read more about the Tyndall effect in another one of our articles Why Do Cosmetic Tattoos Change Colour? - (Part 2).

The reason why melanin appears to be different colours relates to the depth of the melanin within the skin and the spectral characteristics of human skin. The deeper the melanin is within the skin the less red light is reflect back hence a brown pigment starts to appear blue/grey in colour.

If a client/patient already has spots or patches of darkened discolouration in their skin from previous irritation to the skin from things such as acne, skin rashes or infections, cuts or abrasions to the skin etc, or if they have any scars that became darker in colour than the surrounding skin then in most instances they should not have cosmetic tattooing. In the example below the you can see the client/patient is developing patches of PIH secondary to acne.


 PIH Caused by Acne


If there is any doubt whether a client/patient already has, or may develop, PIH then they should have any existing skin blemishes checked by their doctor to determine if they appear to be PIH patches and before a tattoo procedure is considered they should also have a tattoo test patch performed 4-6 weeks before having any cosmetic tattooing procedure. The reaction to the test patch may give you some indication how the clients/patients skin may react to a full tattoo procedure.

The skin colour map below may be used as a guide to the skin tone range most susceptible to PIH due to highlevels of Melanin.


Dark Skin Tones More Prone to PIH


Fitzpatrick Skin types IV-VI are potentially more prone to PIH than types I-III.


Question: What are Fitzpatrick Skin Types? 

Answer:  Fitzpatrick Skin Type is a Classification Scale developed by the late Dr. Thomas B. Fitzpatrick a renowned Dermatologist, you can check your own Fitzpatrick Skin Type by clicking here.

Question: Are there other types of skin disorders that may cause hyperpigmentation? 

Answer:  Yes, conditions such as Lichen Planus, Exogenous Ochronosis, Erythema Dyschromicum Perstans, Drug-induced Hyperpigmentation and Melasama are just a few. Regardless of the cause the same caution is warranted prior to providing a Cosmetic Tattoo treatment.


 Question: What is the recommendation in relation to clients/patients who I suspect may have a hyperpigmentary disorder? 

Answer:  In the vast majority of cases a client/patient with an existing hyper-pigmentation skin condition e.g. PIH or Melasma should not have cosmetic tattooing, clients/patients from Africa, Asia, Latin, and indigenous Indian backgrounds (who are are the most susceptible) should seek medical advice about existing skin blemishes if there is any doubt that they may have PIH type skin blemishes. If the clients/patient advises that a hyperpigmentary condition is present then cosmetic tattooing should not be provided.

If the client/patients doctor advised that in their opinion a hyperpigmentary condition is not evident and if a cosmetic tattoo procedure was then planned it would still be advisable to test patch 4-6 weeks before any tattoo procedure. At the follow up appointment check for signs of abnormal skin discolouration on and around the tattoo patch prior so that you can have more confidence that the client/patient will not have a hyperpigmentary reaction to a full treatment.


Date of most recent revision: 02/01/2013 (mutatis mutandis)
Original publication date: 14/09/2012

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