Don't assume your tattoo is safe: New report says inks could include dangerous bacteria

WORCESTER ― Steven Atkins is in a business whose popularity has skyrocketed, with a growing number of arms and legs and other body parts getting tattoos.

Atkins owns The Black Rose Tattoo Co. on Park Avenue. He moved into a bigger space there because business is booming. But not all developments in the tattoo world are as colorful as the works of art inked in Worcester's 44 licensed body-art establishments.

A recent FDA study warns that some sealed and unopened tattoo inks contain bacteria that can lead to serious health problems, possibly death. Atkins, who opened his business four years ago, said he's not surprised by the findings, given the amount of knockoff inks that anyone can buy on the internet.

“At the end of the day, it’s the responsibility of the tattoo artists” to keep people safe, said Atkins.

The study , published this month in the peer-reviewed scientific journal Applied and Environmental Microbiology, examined 75 bottles of unopened and sealed tattoo and permanent makeup inks, some labeled “sterile,” from 14 different manufacturers. A total of 24 bottles (35%) contained bacterial contamination.

Permanent makeup inks, known as cosmetic tattooing, are used in procedures to improve or replace skin color that’s been lost, often to enhance eyebrows, eyelashes, eyelids and lips.

“Our findings reveal that unopened and sealed tattoo inks can harbor anaerobic bacteria, known to thrive in low-oxygen environments, such as the dermal layer of the skin, alongside aerobic bacteria,” said the study. “This suggests that contaminated tattoo inks could be a source of infection from both types of bacteria.”

The study stressed the importance of monitoring inks for potential contamination.

Atkins held up a bottle of ink in his store marked “sterile” and said he gets his supply from one manufacturer he fully trusts that adheres to more stringent European safety regulations.

What concerns Atkins is cheap imitation inks widely available on the internet that anyone can get their hands on, largely free of any safety protections.

“Those items shouldn’t be sold unless they’re highly regulated,” he said.

The study’s findings come as the lure of getting a tattoo has exploded. Thirty-two percent of U.S. adults have one, including 22% who have more than one, according to the Pew Research Center.

As the numbers rise, so does the risk of infections, said the study. Problems range from mild skin infections to life-threating septic shock that results from extremely low blood pressure and organ failure.

Deeper dive into study results

Beyond 35% of samples contaminated, the study went deeper into the numbers.

Ten different manufacturers, all unnamed, produced the 24 unopened and sealed bottles that were contaminated. Manufacturers from the U.S. and France each accounted for eight of the 24 cases, China had seven and one case was tied to a German manufacturer.

Of the 49 inks with sterility claims on the label, 16 (32.7%) contained bacterial contaminants and 10 of 26 inks (38.5%) without sterility claims were contaminated.

“No significant association was found between a claim of sterility and absence of bacterial contamination,” the study said.

Contamination was higher for permanent makeup inks (17 of 35, 49%) compared to tattoo inks (nine of 40, 18%).

Of the 35 permanent makeup inks, 22 were imported and 13 were manufactured in the United States. Nearly 60% of the imported inks (13 of 22) were contaminated, compared to 31% domestic (four of 13).

Manufacturers: poor job

“My big takeaway is how poorly manufacturers are doing to keep products sterile,” said Dr. Richard Ellison, an infectious disease physician at UMass Memorial Medical Center.

What the study lacks, said Ellison, is a look at nontuberculous mycobacteria, or NTM. These are germs found in soil, dust and water that could contaminate inks during the manufacturing process. NTM outbreaks linked to tattoo inks occurred in 2011 and 2012 in New York, Washington, Iowa and Colorado.

Ellison also worries NTM infections can occur when someone giving a tattoo has wet or dirty hands, causing NTM to enter the skin during a procedure. Clean, safe precautions in tattoo shops are always necessary, he said.

He also said tattoo infections are rare, and he hasn’t encountered one in his career. However, anytime a tattoo needle is inserted in the skin, Ellison said, there is a risk of infection.

“Artists using sterile ink products, doing best practices, there’s still some risk."

US lacks regulations

There are no regulations in the U.S. that require tattoo and permanent ink manufacturers to test and certify their products.

The FDA intends to set up rules consistent with international standards as part of the Modernization of Cosmetics Regulation Act of 2022, according to an FDA document that included recommended safety guidelines for ink manufacturers.

The unenforceable guidelines were issued in June 2023 and include:

• Testing inks for contamination or buying them from suppliers that have done the testing
• Cleaning and sanitizing equipment to ensure the manufacturing process doesn't introduce contamination
• Making sure any cleaning doesn’t negatively alter the composition of the inks before they're shipped out

It's impossible

As Marc Williams sees it, it's impossible for manufacturers to completely sterilize inks. Williams has owned Piercing Emporium and Tattoo on Shrewsbury Street for 28 years and said the only way for manufacturers to guarantee the safety of inks is to have aseptic rooms completely free of germs during the entire manufacturing process, similar to surgical ones in hospitals.

“That’s not going to happen,” said Williams. “It would be too expensive to sterilize an area. That’s big bucks.”

Another risk, as Williams sees it, is the bottles that contain the inks. They could get contaminated during manufacturing or shipping, and that could compromise the inks. Williams wonders how that can be prevented.

In his shop, Williams said staff follow all city and state guidelines to keep customers safe.

“We minimize contamination the best we can."

Court case: Freedom of speech

Body art regulations exist in Massachusetts, resulting from a court case in 2000 that struck down a state law that made it illegal for anyone, other than a doctor, to perform a tattoo procedure. The Superior Court ruling was based on the grounds that limiting the practice to doctors violates the First Amendment to the U.S. Constitution that guarantees free speech, since tattoos are a form of expression.

What resulted was the state Department of Public Health creating body art regulations to guide local health departments to set their own standards and enforcement.

Atkins feels if the rest of the country followed Worcester’s body art regulations, there would be little to worry about when it comes to tattoo safety.

Worcester’s regulations include four primary requirements, according to Atkins: certification in the practices of cardiopulmonary resuscitation, first aid and automated external defibrillator; a grade of C-plus or better in a college-level anatomy course; 4,000 hours working as an apprentice under the direction of a licensed tattoo professional; and completion of a blood-borne pathogen course that must be renewed yearly.

Worcester's 44 licensed body-art businesses are inspected by city staff to ensure compliance with local regulations.

“The City conducts sanitary inspections of Body Art establishments ensuring they are complying with all City Ordinances and Regulations as well as ensuring all inks and dyes are used according to manufacturers instructions and expiration dates,” said Tara Sochia, chief sanitary officer, in a prepared statement.

Too 'risky' for FDA

Ultimately, the FDA is responsible for creating regulations that manufacturers must follow so their inks are sterile, something the agency said it will do. But Atkins doesn’t see that happening, because “it’s too risky.”

Risky in the sense that the FDA doesn’t want legal headaches if there are recalls of tattoo inks, even though the quality of inks has greatly improved over the last 20 years, said Atkins.

Bottom line for Atkins, it’s not the manufacturer's responsibility to keep customers safe. Sure, he would like to see the U.S. adopt strict regulations for companies that make the inks, like the laws in Europe.

But even if that happened, Atkins said, the weight of keeping the public safe falls on his shoulders and others who own tattoo shops. That means buying inks from reputable sources and hiring staff that care as much about preventing contamination as they do about creating art.

“Best practices. Make sure you have them,” said Atkins.

Contact Henry Schwan at henry.schwan@telegram.com . Follow him on X: @henrytelegram .

This article originally appeared on Telegram & Gazette: Don't assume your tattoo is safe: New report says inks could include dangerous bacteria