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Table 1.  Demographic Characteristics of 42 Tattoo Artist Respondents
Demographic Characteristics of 42 Tattoo Artist Respondents
Table 2.  Approach to Inking Skin With Moles or Other Lesions by 42 Tattoo Artists
Approach to Inking Skin With Moles or Other Lesions by 42 Tattoo Artists
1.
Anthony  EP, Godbolt  A, Tang  F, McMeniman  EK.  Malignant melanoma disguised in a tattoo.  Australas J Dermatol. 2015;56(3):232-233.PubMedGoogle ScholarCrossref
2.
Pohl  L, Kaiser  K, Raulin  C.  Pitfalls and recommendations in cases of laser removal of decorative tattoos with pigmented lesions: case report and review of the literature.  JAMA Dermatol. 2013;149(9):1087-1089.PubMedGoogle ScholarCrossref
3.
Varga  E, Korom  I, Varga  J, Kohán  J, Kemény  L, Oláh  J.  Melanoma and melanocytic nevi in decorative tattoos: three case reports.  J Cutan Pathol. 2011;38(12):994-998.PubMedGoogle ScholarCrossref
4.
Heywood  W, Patrick  K, Smith  AM,  et al.  Who gets tattoos? Demographic and behavioral correlates of ever being tattooed in a representative sample of men and women.  Ann Epidemiol. 2012;22(1):51-56.PubMedGoogle ScholarCrossref
5.
Reed  KB, Brewer  JD, Lohse  CM, Bringe  KE, Pruitt  CN, Gibson  LE.  Increasing incidence of melanoma among young adults: an epidemiological study in Olmsted County, Minnesota.  Mayo Clin Proc. 2012;87(4):328-334.PubMedGoogle ScholarCrossref
6.
Bailey  EE, Marghoob  AA, Orengo  IF, Testa  MA, White  VR, Geller  AC.  Skin cancer knowledge, attitudes, and behaviors in the salon: a survey of working hair professionals in Houston, Texas.  Arch Dermatol. 2011;147(10):1159-1165.PubMedGoogle ScholarCrossref
Research Letter
April 2017

Tattoo Artists’ Approach to Melanocytic Nevi

Author Affiliations
  • 1Department of Dermatology, University of Pittsburgh, Pittsburgh, Pennsylvania
JAMA Dermatol. 2017;153(4):328-330. doi:10.1001/jamadermatol.2016.5243

Tattooed skin can be challenging to examine for the dermatologist performing a skin cancer screening. A tattooed melanocytic nevus may hide or mimic features of malignant abnormality.1,2 Several case reports have been published describing cases of melanoma diagnosed at potentially later stages owing to concealment in a tattoo.3 To our knowledge, no studies have evaluated tattoo artists’ approach to skin with nevi or other skin lesions. We used a survey to investigate whether tattoo artists consider the risk of skin cancer before inking skin with nevi, whether they deliberately avoid skin lesions, and how commonly they perceive a skin lesion to be suspicious and encourage the client to see a dermatologist.

Methods

This study was determined to be exempt from full review by the University of Pittsburgh institutional review board. An anonymous survey of 42 professional tattoo artists was distributed between July 15 and August 15, 2016, after obtaining verbal consent. Data was analyzed using Fisher exact tests.

Results

The median amount of work experience among respondents was 8 years (Table 1). Most respondents reported having declined to tattoo skin with a rash, lesion, or spot in the past (Table 2). The most common reasons were a potentially poor cosmetic outcome, concern for interfering with skin cancer, and potentially causing bleeding at a mole site. Seventeen (40.5%) of 42 respondents reported that they tattoo around a mole or other skin lesion, while 18 (42.9%) reported either tattooing over them or deferring to the client’s preference. Most respondents reported that clients never ask them to avoid tattooing moles or skin spots. Respondents who had previously seen a dermatologist for a skin examination were more likely to decline to administer a tattoo (P = .01) and recommend a client see a dermatologist for a skin lesion perceived suspicious (P < .001). Respondents who had received specific training were more likely to decline to administer a tattoo (P = .01).

Discussion

Our findings show that tattoo artists’ approach to nevi and other skin lesions is not standardized. While most of those surveyed reported deliberately avoiding nevi, a similar proportion reported either tattooing over them or simply deferring to the client’s preference. This is concerning because few clients specifically ask tattoo artists to avoid skin lesions, highlighting an opportunity for patient and tattoo artist education. As respondents considered whether to tattoo skin with nevi or other skin lesions, the predominant consideration was their client’s final cosmetic outcome and not the potential for skin cancer. This may lead tattoo artists to ink over perceived benign-appearing skin lesions that do not otherwise affect the quality of a tattoo but that may represent an early form of skin cancer. Respondents who had prior skin examinations were more likely to decline to administer a tattoo, as well as refer a patient to a dermatologist. An increased awareness of the risk of skin cancer may lead these respondents to be more discerning. However, whether respondents gained this increased awareness owing to education received at prior skin examinations, or if an increased awareness led them to seek skin examinations in the first place, is unknown. There has been a significant rise in melanoma incidence among young adults, some of the most frequent tattoo customers, making surveillance by tattoo artists especially important.4,5 Our study highlights an opportunity for dermatologists to educate tattoo artists about skin cancer, particularly melanoma, to help reduce the incidence of skin cancers hidden in tattoos and to encourage appropriate referral to dermatologists for suspicious lesions on clients, similar to efforts to train hairdressers to recognize and refer patients with lesions that are concerning for scalp melanoma.6 A prospective study assessing the effect of skin cancer education on a cohort of tattoo artists may provide greater evidence for this recommendation.

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Article Information

Corresponding Author: Timothy J. Patton, DO, UPMC Department of Dermatology, Falk Medical Center, 3601 Fifth Ave, 5th Flr, Pittsburgh, PA 15213 (pattontj@upmc.edu).

Accepted for Publication: November 8, 2016.

Published Online: January 18, 2017. doi:10.1001/jamadermatol.2016.5243

Author Contributions: Dr Patton and Mr Mori had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Mori, Ferris, Patton.

Drafting of the manuscript: Mori.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Mori.

Obtained funding: Mori.

Administrative, technical, or material support: Mori, Peters.

Supervision: Ferris, Patton.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the University of Pittsburgh School of Medicine Scholarly Project Program.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Anthony  EP, Godbolt  A, Tang  F, McMeniman  EK.  Malignant melanoma disguised in a tattoo.  Australas J Dermatol. 2015;56(3):232-233.PubMedGoogle ScholarCrossref
2.
Pohl  L, Kaiser  K, Raulin  C.  Pitfalls and recommendations in cases of laser removal of decorative tattoos with pigmented lesions: case report and review of the literature.  JAMA Dermatol. 2013;149(9):1087-1089.PubMedGoogle ScholarCrossref
3.
Varga  E, Korom  I, Varga  J, Kohán  J, Kemény  L, Oláh  J.  Melanoma and melanocytic nevi in decorative tattoos: three case reports.  J Cutan Pathol. 2011;38(12):994-998.PubMedGoogle ScholarCrossref
4.
Heywood  W, Patrick  K, Smith  AM,  et al.  Who gets tattoos? Demographic and behavioral correlates of ever being tattooed in a representative sample of men and women.  Ann Epidemiol. 2012;22(1):51-56.PubMedGoogle ScholarCrossref
5.
Reed  KB, Brewer  JD, Lohse  CM, Bringe  KE, Pruitt  CN, Gibson  LE.  Increasing incidence of melanoma among young adults: an epidemiological study in Olmsted County, Minnesota.  Mayo Clin Proc. 2012;87(4):328-334.PubMedGoogle ScholarCrossref
6.
Bailey  EE, Marghoob  AA, Orengo  IF, Testa  MA, White  VR, Geller  AC.  Skin cancer knowledge, attitudes, and behaviors in the salon: a survey of working hair professionals in Houston, Texas.  Arch Dermatol. 2011;147(10):1159-1165.PubMedGoogle ScholarCrossref
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