Why Do Cosmetic Tattoos Change Colour? - (Part 2)

by Andrea Darby - Master Medical Tattooist & Industry Educator
Why Do Cosmetic Tattoos Change Colour

We receive lots of enquiries from Cosmetic Tattooists about why their tattooing might change colour, it seems that many within the industry including pigment manufacturers are vexed by this particular problem, this is part 2 of a 2 part article.

This is Part 2 of the 2 part article "Why Do Cosmetic Tattoos Change Colour?"

You can read Part 1 by clicking here.

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Why do tattoo pigments fade or change colour and why do technicians sometimes get unexpected effects or colour outcomes after cosmetic tattooing?

Factors Related to the Methods and Techniques of the Tattooist

Needle Depth
- needle depth can have a significant effect on the surface appearance of a cosmetic tattoo, pigment depth will affect both the apparent size and colour of the pigment. This is due to the unique spectral characteristics of human skin, blue light does not tend to penetrate very deeply into the skin but has more scatter and reflectance, red light penetrates more deeply and both have progressively less reflectance with increasing depth in the dermis. The differences between long and short wavelength light reflectance in a colloid was first described by the physicist John Tyndall during the late 1800's and became known as the Tyndall effect.

If the pigment is not implanted at the correct depth within the dermis then Black/Brown pigments may tend to appear Blue/Green/Grey because of depth related changes to red light reflectance, similar effects are seen with pigmentary disorders such as Post Inflammatory Hyper Pigmentation (PIH), and Melasma where melanin can appear to be Black/Brown/Blue/Grey depending on the depth of the melanin deposit within the skin. All pigment colours may be altered in appearance if incorrect implantation depth is used due to the Depth: Colour/Size effect.

The Depth: Colour/Size effect is illustrated in the image below.

Pigment depth, colour and size relationship

In the example above we have two deposits of pigment side by side, the surface appearance of the pigment changes as the implantation depth changes within the skin initially appearing to be brown then a greenish blue, then grey, and finally not being visible due to complete loss of light reflectance.

At the same time there is also an apparent change in size, for example a deposit at a depth of 500µm will appear to be more than three times its actual size7. As depicted in the illustration larger deposits are more susceptible to colour and size alterations related to implantation depth than smaller deposits, but the required 'size threshold' is smaller than is applied during most cosmetic tattoo procedures therefore the Depth: Colour/Size effect would be a factor in most procedural outcomes.

Type of Tattoo Equipment Used
- An important point with regards to choice of equipment is that depth related colour change may be more obvious with high precision digital tattoo machines than with lower precision equipment, this is because low precision equipment will tend to implant pigment at constantly varying depths within the skin which may tend to mask incorrect implantation depth settings by the technician. In contrast high precision equipment will tend to consistently implant pigment at exactly the depth settings that were selected and if the depth setting was incorrect then depth related pigment colour change may occur.

In the illustration below you can see an exagerated example how the sideways oscillation of the needle with a standard rotary pen may implant pigment at multiple depths as it tears and hacks at the skin with imprecise needle penetrations. In contrast the use of a precision digital machine is likely to implant the pigment at the precise needle depth that was selected, for this reason use of precision equipment requires the correct settings by the technician.

Standard Rotary Pen vs Precision Digital Machine

For the same reasons very deep implantation of pigment using low precision equipment may still result in visible pigment after healing due to constant variability of the implantation depth, but with high precision equipment it is possible that a very deep implantation of pigment may not even be visible after healing if there is not at least some pigment implanted in the visible reflectance regions of the dermis.

Refer to the illustration under the 'Needle Depth' heading above again when reading the next point.

Needle Angle
- There is a trend towards using slope needles (which are intended to be used at a 45° angle) and some other needles such as 4 flat are sometimes used the same angle. Part of the rationale for using needles on a 45° narrow angle is that if pigment is implanted with the needle close to vertical position e.g. between 80-90° then pigment will tend to be squeezed back out of the skin penetration opening as the needle retracts from the skin, but if the needle enters on an 45° angle then more pigment may tend to be retained due to tighter closing of the skin opening as a result of the angle of needle insertion.

There are two important factors to be aware of in relation to changing technique from a 80-90° to a 45° needle angle;

  1. A 45° degree angle will require roughly 40% more exposed needle to achieve the same penetration depth as the same needle used on a 80-90° angle, this is simply due to the geometry of the needle slope as can be seen in the illustration below.
  2. Due to the increase in exposed needle required to achieve the same depth and also due to the angle of insertion the appearance of the tattoo, as shown in red colour, may seem different when observed from the skin surface if a 45° angle is used in comparison to a 80-90° angle.


 Tattoo needle angle


You learned earlier in this article how important needle depth is in relation to the final healed colour and size appearance of a tattoo, and in this illustration we can also see that needle angle also changes the amount of exposed needle needed to achieve the required depth and also the surface appearance of the tattoo. Both the needle depth and angle can have an impact on the appearance of tattoo colour, size, and shape.

Needle configuration - The choice of needle configuration can have profound effect on the final healed colour of a tattoo, for example tightly grouped needles such as power needles will tend to implant pigment at a higher density which will concentrate the pigment colour in the skin (higher pigment/skin saturation). More loosely grouped needles such as rounds or shaders will not implant pigment at quite the same density therefore the final healed colour may seem less intense and more of the natural skin colour may be visible within the final healed colour altering the hue of the tattoo.

The correct choice of needle configuration is essential to achieve the required colour and effect outcome.

Needle Passes - Intuitively the more passes over the skin the more pigment is likely to be implanted, however excessive passes will increases trauma and bleeding which can push pigment out of the skin, or even worse it can cause pigment migration which affects the final colour as well as causing an undesirable appearance.

Inappropriate Choice Of Pigment Colour Relative to the Clients Skin Tone - In most cases the final healed colour of a cosmetic tattoo will be a composite blend of the clients natural skin undertones, the pigment colour, the obscuring effect that occurs during pigment fixation and any natural skin overtones. Therefore the clients skin tones will have a significant effect on the final healed colour and must be taken into consideration when selecting the tattoo pigment colour.

For example in the illustration below we have the same pigment colour applied to three completely different skin tones and the comparison to initial colour after tattooing as well as the final healed colour in 4-6 weeks after tattooing. You can see from the illustration that selecting an appropriate choice of pigment colour in relation to the clients natural skin tones is very important.

Tattoo pigment & different skin tones

Pigment Density (pigment/skin saturation) - As mentioned above the choice of needle type, the number of passes over the skin, and the total number of treatments applied will all affect the density of the pigment within the skin and the final healed colour. Both the technician and the client need to be aware that pigment density will affect the hue of the tattoo not only because of relative concentration of the pigment colour as the density increases but also because increasing pigment density reduces the combined affect that the natural skin colour has on the final healed colour of the tattoo. The exception to this is skin tones with high levels of melanin which may have an overpowering effect on the final healed colour of the tattoo regardless of pigment density.

Pigment Mixing - Those who have had any formal education in the art of painting will be aware of the term creating a 'mud mix' or creating 'muddy colours' this is a situation that occurs due to over mixing of paint colours, the more mixing of colours that you do the muddier the colour tends to become resulting in a dull hue that is much closer to a greyish: brown/blue/green/red than the individual component colours that you began with.

Most cosmetic tattooists seem to use the paint artists intuitive colour model of Red, Yellow, Blue, (RYB), the difference being that the paint artists have the luxury of starting with paint colours that are very close to their very vibrant primaries Red, Yellow, Blue. Cosmetic Tattooist do not have the luxury of starting with pigment colours that close to the RYB primaries most of our pigment colours are already secondary or more likely tertiary colour mixtures.

In fact no matter which colour model you prefer; Red, Yellow, Blue, (RYB) or Cyan, Magenta, Yellow, Black, (CMYB), Cosmetic Tattooists rarely ever work with colours that are even close the the primaries of any of the colour models.

So what does that mean?

Answer: It means that the premixed tattoo pigments that you are using are already one or two steps towards a 'mud mix' this is because unlike body art tattooists cosmetic tattooists do not tend to use extremely bold vibrant colours they use softer muted hues that look more natural. If you examine the ingredients of your cosmetic tattoo pigments you will find that they often contain 2-3 colourant ingredients and those starting ingredients probably were not very close to being primary colours either.

It is important to keep in mind that the clients natural skin tones also contribute colours to the final healed colour of the cosmetic tattoo and the skin tones may add 3-4 or more individual colour influences e.g. fat (yellowish), blood (red/blue/maroon), blood vessels (blue/green/turquoise), melanin (yellow/red/brown/black), un-pigmented epidermal skin (white/creamy/yellowish). Therefore the client is already making some significant colour contributions to the final healed tattoo colour and the process of pigment fixation also will tend to make any pigment colour less vibrant and a muddier hue.

If you mixed two cosmetic tattoo pigments together that both had 3 colourant ingredients and lets assume that each of the colourants are already RYB tertiaries, then the resulting colour will be a mixture of 6 tertiary colours which will be getting perilously close to a mud mix.

The image below illustrates this point, two cosmetic tattoo pigments are mixed together both of the pigments were already blends of tertiary colours that resulted in very soft hues and after mixing them together the pigment mix is very muddy and once applied to a bluish skin colour the result is an unattractive muddy grey tattoo colour.

Tattoo pigment creating a Mud Mix

For some reason some cosmetic tattooists insist on mixing pigment colours together unnecessarily, if your pigment range has been created by a qualified pigment chemist then the range most likely already has most of the colours that you will need and the chemist should have been careful not to mix too many colourant ingredients together in the creation of each pigment.

Key Point: It is far better to select a premixed pigment colour than to try and create a colour by mixing pigments together because the more colourant ingredients that you add together the more likely the resulting colour will be a mud mix.

Cosmetic Tattooists who have a comprehensive understanding of pigment colour and an arts background generally will only occasionally mix two pigment colours together and will rarely ever mix three pigment colours together because you will achieve a better outcome by selecting a premixed pigment that is already the colour that you require.

Additional caution is also warranted if mixing pigments from different manufacturers because incompatibilities between colourants, thickening agents, solvents and antimicrobial additives between different brands may cause unexpected interactions and colour outcomes.

Alkalising The Skin - We strongly advise against the use of alkaline topical anaesthetics such as Emla cream prior to cosmetic tattooing because of the pH of the product, Emla has a pH of around 9.0-9.2 and therefore it can be dangerous if used near the eye and there are reports within the medical literature of chemical injury to the eye caused by use of Emla cream8.

Also we quote: "
the effect of a strongly alkali cream on a tattoo pigment colour could be both pronounced and unpredictable".

As discussed previously particle size is particularly important with tattoo pigments because particles that are too small are more likely to migrate within the skin into unwanted locations and small particles are more susceptible to metabolism and transportation by the immune system. Most pigment manufacturers would be aware that there is particular importance in relation to carbon based pigments to ensure that the particle size is large enough to ensure stability within the skin.

Obviously it would be a large undertaking to conduct experiments to test all the colourants used by the different pigment manufacturers to assess if alkalising their various pigments caused any unusual reactions or colour changes. We decided to test a single pigment type containing carbon as we concluded that carbon particles may be particularly susceptible to alkalisation.

A small scale comparative experiment was conducted as per the following summary;

Vial 1 - 15ml Distilled water + 0.01ml Carbon Black Pigment: light agitation for 30 seconds to ensure even mixing.

Vial 2 - 15ml Distilled water + 0.01ml Carbon Black Pigment + 0.01ml pharmacy compounded 5% Lidocaine Cream with pH<7.8: light agitation for 30 seconds to ensure even mixing.

Vial 3 - 15ml Distilled water + 0.01ml Carbon Black Pigment + 0.01ml Emla Cream: light agitation for 30 seconds to ensure even mixing.

All three vials were left standing for 16 hours and reviewed every 2 hours to permit adequate time for alkalisation of the carbon to take place.


Vial 1 (control) - As expected we noted that after 2 hours most of the carbon in vial 1 had dropped out of suspension to the bottom of the container, particles seemed to be intact and to settle easily.

Vial 2 - Particles took longer to drop out of suspension, after 8 hours most of the particles had fallen to the bottom of the container with some even coating on the container walls.

Vial 3 - Even after 16 hours most of the carbon in vial 3 was still in suspension, visually the carbon in vial 3 seemed to be far more miscible.

See image below depicting the 3 vials after 16 hours.

Vial 1

Vial 2

Vial 3

Alakalising carbon based tattoo pigments

Our conclusion is that alkalising the carbon with the addition of a small quantity of a topical anaesthetic with pH 9.0-9.2 caused a rapid change in the structure and or behaviour of the carbon particles, even the anaesthetic with a lower pH had some observable differences compared to the control vial 1.

The exact mechanism is unclear but there are some possible explanations for the results we observed, it is known that carbon can be activated with the addition of sodium hydroxide (NaOH)9, carbon activation results in increased surface area of the carbon particle by riddling it with small holes, also NaOH has been used in conjunction with industrial pigments to aid in carbon dispersal (achieving a more even spread), it is also possible that particle sizes may have been reduced. Regardless of the mechanism involved it was apparent that the addition of the topical anaesthetic increased dispersal of the pigment and the strongly alkaline anaesthetic had the most marked effect on the pigment.

We acknowledge that our experiment was by no means conducted to laboratory standards and differences both in the active ingredients of the two topical anaesthetics and their respective carriers may have had an affect on the outcome. However we draw the reasonable conclusion that alkalising the skin prior to implanting a tattoo pigment has the potential to increase the risk of pigment migration in the skin, particularly if a carbon based pigment is used, as a direct consequence of increased pigment dispersal.

For the above reasons we caution against using alkaline topical anaesthetics prior to cosmetic tattooing, also it appears that even anaesthetics with a more neutral pH may have a very slight tendency increase pigment dispersal in the skin if they are used excessively or permitted to mix with the pigment during the tattoo procedure.

Factors Intrinsic to the Client

Natural Skin Colour - As mentioned previously your clients natural skin colour will contribute to the final healed colour of the tattoo. Unfortunately those clients who have high levels of melanin in their skin will not be able to achieve some final colour outcomes from Cosmetic Tattooing and outcomes may also be less predictable. This is because melanin is deposited inside keratinocyte cells in the epidermis above the tattoo pigment and to a lesser extent sometimes also within cells in the dermis, the image below provides an example.

Melanin and tattoos

High levels of melanin in the skin above the tattoo pigment may partially or completely obscure the tattoo pigment depending on the density of melanin, how dark the natural skin colour is, and the colour and density of the tattoo pigment that was used.

You will also note that if melanin is located deep within the dermis it can appear to be blue/grey in colour this sometimes occurs with pigmentary disorders such as Post Inflammatory Hyperpigmentation (PIH) or Melasma, in the same way that depth affects the appearance of the colour of a tattoo pigment it also affects the appearance of the colour of melanin.

If the skin has high levels of melanin even if melanin was beside and beneath the tattoo pigment (usually not the case) it would still have a significant effect on the final healed colour of the tattoo, but because melanin is generally deposited into epidermal cells (above the tattoo pigment) it often has an overpowering effect on the final healed colour of a tattoo and may obscure the tattoo pigment completely, the image below illustrates this concept.

Melanin obscuring tattoo colour

Those technicians who have tattooed the lips of a client who has dark brown or black lips may have experienced this phenomenon, attempts to lighten the lip colour sometimes failing completely. If the client is prone to Post Inflammatory Hyperpigmentation then the lips may actually become darker after tattooing because the trauma to the lips during tattooing has stimulated the production of even more melanin and if the melanin is deposited above the tattoo pigment there may be no visible trace of the tattoo pigment at all or the overall colour result may be an unusual dark brown/black/grey hue.

Obviously it is not impossible to provide cosmetic tattooing to clients with darker skin tones but the more melanin there is the more difficult it is to achieve certain colour outcomes, the less predictable the results will be, and the more prone the client may be to develop PIH after tattooing.

Metabolism/Transportation of the Pigment -
When tattoo pigment is implanted into the skin specialised immune system cells recognise the pigment as a foreign material and attempt to phagocytose (engulf and digest) the pigment or simply break the particles down so that it can be removed from the skin and transport into the lymphatic system. However tattoo pigment particles tend to be quite large in size, fairly inert (low chemical reactivity) and are not easy to phagocytose or break down, eventually the immune cells compromise by surrounding the pigment and attempting to isolate it with the help of fibrin filaments (the building blocks of scar tissue) which help to prevent the pigment moving around and ultimately fixes the pigment in place.

Over time immune cells may persist with attempts to phagocytose and transport the pigment and some clients may have particularly active / successful immune systems that eventually manage to metabolise or transport some or all of the tattoo pigment. Because cosmetic tattoo pigments are often composed of 2-3 colourant ingredients if the immune system is more successful at metabolising or transporting one of the ingredients compared to the others then the tattoo will start to change colour to reflect the dominant hue of the remaining colourant ingredients.

The effect in this situation will be very similar to what can occur if the colourant ingredients are not lightfast balanced as described previously, the difference being that colour changes related to Lightfast imbalance are likely to affect more clients and colour changes related to Metabolism/Transportation of the Pigment are likely to affect fewer clients when using the same pigment.

Pigment Sloughing
- If you have ever had a splinter of wood, metal, or glass embedded in your skin you may have experienced how the splinter can be ejected out of the skin surface sometimes days, weeks, months or even years after you first got the splinter. If you have a foreign body in the dermis the closer it is to the stratum germinativum/basale (which is the deepest layer of the epidermis) the more likely it is that the foreign body will be pushed out into the epidermis and then be shed during the keratinisation cycle.

If a cosmetic tattoo has been performed correctly then the pigment will have been implanted into the top third of the dermis and therefore it is more likely that some of the tattoo pigment may slough off over time if the skin is successful at expelling the tattoo pigment into the epidermis. The image below illustrates how once pigment is close to the stratum germinativum it is more likely to be expelled.

Sloughing of tattoo pigment


Changes to Skin Thickness - As discussed previously the depth that tattoo pigment is implanted into the dermis can alter the appearance of the colour and apparent size of the tattoo. Pigment that is close to the epidermis will appear to be closer in colour to the original pigment colour and pigment that is deeper in the dermis may appear to be more blue/green/grey than the original pigment colour. This occurs due to the spectral characteristics of the skin particularly the dermis, naturally anything that causes the epidermis or dermis above the tattoo pigment to increase or decrease in thickness will change the relative depth of the pigment within the skin which may alter the apparent colour of the tattoo.

There are a wide range of potential causes for changes in skin thickness a few examples are listed below;


  • UV light exposure
  • Inflammatory skin conditions - e.g. dermatitis, eczema, psoriasis etc
  • Allergic skin conditions
  • Medical conditions - e.g. diabetes mellitus, hypothyroidism, scleroderma, erythroderma etc
  • Medicines - e.g. bleomycin sulphate


  • Age - skin thickness tends to reduce with advancing age
  • Excessive & prolonged UV light exposure leading to skin damage
  • Corticosteroid creams and ointments
  • Menopause
  • Exfoliation treatments and therapies

Natural Skin pH - Our epidermal skin surface tends to be naturally acidic and the pH can vary quite a lot 4.0-7.0. It has been suggested by some cosmetic tattooists that those with the more acidic skin types might affect some of the colourant ingredients within tattoo pigments. However it needs to be borne in mind that the pH of the epidermal surface is not equivalent to dermis pH where the tattoo pigment has been implanted.

The dermis has been found to have a mean extracellular pH 7.54+/- 0.09 (S.D.)10 and natural variations in dermal pH are quite modest even during episodes of extreme hypoxia e.g. a variance of 0.02 +/- 0.02 (S.D.).

With these factors in mind we consider it to be highly unlikely that variations in natural skin surface pH will affect tattoo pigments that are implanted in the dermis which it seems remains close to neutral pH regardless of variations in the natural skin surface pH.

Factors Related to the Clients Environment & Medicines

UV Exposure - Ultraviolet B (UVB) radiation causes sunburns, Ultraviolet A (UVA) radiation doesn't burn the skin but penetrates much deeper into the skin, and both have the potential to cause skin damage and fading of tattoo pigments. Sources of UV radiation include sunlight, tanning studios, and even some indoor lighting sources such as halogen lamps which emit significant levels of ultraviolet radiation and fluorescent bulbs which can emit varying levels of ultraviolet radiation depending on the type11-12.

In addition to fading the tattoo pigment UV light exposure can obviously change skin colour due to tanning, and as discussed above melanin is deposited into keratinocyte cells in the epidermis above the tattoo pigment which will not only change the overall colour of the tattoo but may make it less visible.

Skin Treatments -
Obviously if the client has laser/fraxal treatments, dermabrasion, chemical peels, or any other form of aggressive skin treatments they can potentially affect the colour of a cosmetic tattoo.

Alcohol Consumption
- Alcohol may have an anticoagulant effect due to reducing platelet aggregation, platelets are specialised blood cells that are an essential part of the complex process of blood clotting. Consumption of alcohol can interfere with normal blood clotting both during the 24-48 hours after consumption for occasional drinkers and for more prolonged periods for regular drinkers (3-6 drinks/week).

For this reason clients who are regular drinkers or those who drink alcohol in the 48 hours before or after tattooing may experience more bleeding than usual, and as we know bleeding during or immediately after tattooing can cause pigment migration.

Tobacco Smokers
- Nicotine acts as a vasoconstrictor and intuitively you may think that would reduce bleeding, however tobacco smoking is also associated with increased risk of haemorrhage after some types of surgery and increased risk of cerebral vascular accidents (stroke). The increased risk of haemorrhage is most likely due to the vasoconstrictor effect causing higher blood pressure for smokers.

Most experienced cosmetic tattooists have probably noticed that smokers often tend to bleed a little more than non smokers during tattoo procedures and once again bleeding during or immediately after tattooing can cause pigment migration.

There are two other unwanted effects that can potentially occur for regular smokers after lip tattooing;

Heavy Smokers - Can cause brownish/yellow lip staining similar to what can occur on the fingers of smokers.

Regular Cigarette Smokers - Can experience a loss of pigment generally or just in the lip-filter-zone this is the area of the lips where the smoker rests the cigarette filter during smoking. Cigarette filters are highly absorbent and they have the ability to have a drawing effect on pigment during the initial healing period, also the regular pursing and inhaling through the lips (drawing in) during the act of smoking can tend to squeeze pigment out of the skin during the initial healing period.

Loss of pigment in due to smoking

For this reason regular smokers may develop patchy loss of tattoo pigment after lip tattooing particularly in their lip-filter-zone, using cigarette holders during healing may lessen the risk slightly.

Laser Tattoo Removal
- can cause significant colour changes to a tattoo pigment during the course of treatments, for example pigments containing white titanium di/oxides, which are often used to soften or lighten cosmetic tattoo pigments, may turn vivid blue/grey/black even after a single laser tattoo removal treatment. Titanium is also an extremely robust material therefore it can prove difficult to break down without numerous laser removal treatments, for that reason clients should give careful consideration to all available options before undergoing laser tattoo removal in instances where their tattoo pigment contains titanium.

Skin creams and lotions - A wide variety of skin creams and lotions may affect the colour of a cosmetic tattoo if used immediately after tattooing or in the longer term, below are just a few examples;

  • Retin A Creams - There is some anecdotal and experimental evidence to suggest that Tretinoin may cause premature fading of cosmetic tattoo pigments 13-14.
  • Vasodilators - Use of vasodilators such as Minoxidil after a cosmetic tattoo treatment may cause increased bleeding which could result in a reduction pigment density and pigment migration particularly if used prior to tattooing or during the initial healing period.
  • Skin Acidifiers/Alkalisers - frequent use of strongly acidic or alkaline creams or lotions such as alpha hydroxy acids; citric acid, glycolic acid, lactic acid, malic acid and tartaric acid or hydroxide skin washes and sprays all have the potential to cause premature fading or colour changes in the cosmetic tattoo pigment.
  • Chlorine/Bleaching agents - Use of chlorinated swimming pools or use of skin bleaching creams and lotions such as Hydroquinone also have the potential to cause premature fading and colour changes in cosmetic tattoos.

Oral Medicines -
There seems to be a number of body art tattooists who claim that clients who were taking oral antibiotics for serious illnesses (such as Lyme disease) at the time of tattooing resulted in a duller less vibrant healed tattoo than they anticipated from their previous experience either with the client or the tattoo pigment. We were unable to find any reports within the medical literature that would provide an explanation for that type of effect, although we acknowledge that a treating physician is unlikely to publish a medical case report relating to the outcome from tattooing unless it had a tangible relationship to the medical treatment and or care of their patient.

Therefore without first hand knowledge we cannot support or discount the tattooists claims about antibiotics, what we can say is that in most circumstances clients who have an active infection that requires the use of antibiotics should not be undergoing tattooing anyway.

Anecdotally we have observed two cases of highly unusual changes following cosmetic tattooing by other service providers where we established the clients where taking oral Bisphosphonate therapy at the time of tattooing. Bisphosphonate therapy which sometimes called diphosphonate’s (e.g. Actonel, Fosamax) are a class of prescription drugs that inhibit osteoclast action and the resorption of bone, Bisphosphonate have a high affinity for calcium ions, its uses include the prevention and treatment of osteoporosis and it may also be prescribed for patients being treated for cancer particularly if there are metastasis in the patients bones.

Patients who are taking Bisphosphonate are usually advised by their doctor not to undergo non-essential invasive procedures of the mouth such as dental extractions because of the risk of Osteonecrosis of the jaw (ONJ), for this reason lip tattooing would be contraindicated in most circumstances for patients who are taking Bisphosphonate therapy.

In regards to the two cases referred to us, in both circumstances the clients had experienced unusual changes to their cosmetic tattoo within a few days after tattooing by their respective technicians, both were taking oral Bisphosphonate therapy at the time of tattooing and both experienced sudden colour changes and pigment migration similar to what might be expected after laser tattoo removal treatments.

In the image below 7-10 days after tattooing the client experienced almost complete loss of pigment, sudden colour change of remaining pigment from the original red colour to a blue/black, and obvious pigment migration. Apparently the original technician then repeated the treatment and exactly the same outcome occurred within a few days, there did not seem to be anything unusual or remarkable about the clients circumstances or the treatment provided other than the Bisphosphonate therapy and the unusual outcome from the tattooing.

Bisphosphonates and cosmetic tattooing

In both cases we referred the clients to their treating doctors for further evaluation and management prior to consideration of any corrective tattooing.

We have been unable to find any prior reports within the medical literature of a similar nature but once again we wonder about the likelihood that medical practitioner would publish a case report about the outcome from cosmetic tattooing unless it directly related to the health of their client, e.g. cosmetic tattooing impacting on the clients health or medical treatment rather than the other way around.

We stress that a relationship between the outcome from the cosmetic tattooing and the medication that the clients were taking is purely speculative and unproven however we consider that there are grounds to at least consider the possibility of a theoretical link for the following reasons;

  • Diphosphonate products have been used industrially for the purposes of corrosion inhibition in ferrous pipes and boilers by assisting to dissolve loose iron oxide build up, reducing particle size, and maintaining the oxides in suspension so they can be easily flushed out.
  • Many metal ions are made soluble in different solvents using specific chelating agents, a chelating agent is something that can bind to a metal ion in solution. The metal itself might be highly insoluble in a particular solvent but a chelating agent can grab hold of the metal ion enabling the solvent to dissolve the chelate and then in effect the metal ion is made soluble.
  • A compound/drug that contains a phosphate or diphosphate could potentially act as a chelating agent.

Once again we stress that the relationship is highly speculative, in vitro chemistry (in the lab) can be significantly different to in vivo biochemistry (in the body) but at the very least it highlights the reason to always consider your clients medications and health status and refer the client to their treating doctors particularly when there are very unusual and unexpected outcomes from cosmetic tattooing.



Special thanks to Mr. Darren Kelly (chemist) and managing director of Drucegrove Ltd, Mr. Kelly's knowledge of colourants and his clarification of issues pertaining to practical & theoretical chemistry were of great assistance in the creation of this article.


Date of most recent revision: 14/09/2013
Original publication date: 14/09/2013

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