Tattoos are permanent imprints on the skin created by deposition of ink into the dermis through a series of punctures using a sharp object.5
The art of tattooing has been in practice for hundreds of years by many cultures across each continent that can be dated back to 4000 B.C. The English term tattoo has its origins from the Polynesian language and is thought to be most directly derived from the Samoan word tatau
Samoa is an archipelago in the South Pacific roughly halfway between Hawai‘i and New Zealand. The Samoan natives are steeped in custom and have been practicing the art of tattooing since 1500 B.C.6
These creations are more than symbols of beautification as they signify respect for a man's courage and transition through manhood — a symbol of high social status and a prerequisite to receiving a Chief title. Despite early missionary attempts to outlaw this practice, the tradition has thrived in Polynesia and continues today as it was in the past.2
When a needle pierces the outer layer of the skin, the dye is carried along the surface through the wound tract in the upper and middle aspects of the dermis.7
An inflammatory process is stimulated causing superficial epidermal sloughing and influx of inflammatory cells, exposing the basilar layers. In the dermis, most of the pigments aggregate within the papillary and reticular layer. Eventually, there is gradual assimilation of the pigment into macrophages. The majority of these macrophages migrate to regional lymph nodes, while the remaining population forms the permanent tattoo.4
The most common adverse effect from tattooing is a local bacterial infection, occasionally severe enough to cause necrosis, amputation, or even death.4
This was reported as early as the 19th century among French sailors receiving tattoos. Such complications were not surprising given the general lack of sterility, use of contaminated needles, and application of substances such as urine or saliva during the tattoo process. Today, these complications are rare in the professional tattoo community with the adoptation of sterilization, standardization of equipment, and the availability of antibiotics in the event of a cutaneous infection.3
With the emigration of Samoans throughout the Pacific basin, traditional tattooing has followed. These tattoos are a popular means of connecting to their homeland and its heritage. The sense of pride in receiving a tattoo in the traditional manner may lead to acceptance of poor antiseptic techniques involved in the tatau
A strong desire to preserve this traditional process has frequently discouraged young Samoan men from using antibiotics or painkillers during the tatau
Unlike Western tattooing techniques that only penetrate through the upper layers of the skin, tapping of the instrument in Samoan tradition requires some force. This primitive technique usually drives the teeth of the instrument through several layers of skin causing more injury and exposure to the outside environment.
Surprisingly, there are only a few reported cases of life threatening complications linked to traditional tattooing. The earliest report was documented by Korman of Australia in 1994.10
The traditional technique involved use of a sharpened boar's teeth and application of paste consisting of kerosene and turmeric over the tattooed areas of a Samoan male. After developing thigh inflammation, the man presented one week later with acute illness and was found to have polymicrobial septicemia with Pseudomonas aeruginosa and Streptococcus pyogenes.
In Auckland, New Zealand there has been a resurgence of traditional tattooing performed by resident tufuga ta tatau
. In 2003, Porter, et al, described two cases of necrotizing fasciitis and cellulitis, one resulting in death, following traditional tattooing.11
An investigation of the two cases had similar causal themes to include improper sanitary conditions and late presentation of infectious complications because of unwillingness to access medical services as an expectation of tradition and a misunderstanding of the presenting symptoms.
Two additional cases in New Zealand were reported by McLean et al in 2010.12
The first suffered from extensive cellulitis and necrosis with wound cultures identifying Staphylococcus aureus
and Group C Streptococcus. The other involved severe septic shock and multi-organ failure from necrotizing fasciitis with abdominal wound cultures demonstrating Group A Streptococcus and Pseudomonas aeruginosa. Both men were immune to Hepatitis B. Further investigation through survey of regional general practitioners and emergency departments revealed eight additional cases of cellulitis with varying degrees of severity. Five of these cases were linked to the same tattooist who was known as an experienced traditional Samoan practitioner that worked from his garage. Microbiology testing performed on his tools isolated the same strain of Group A streptococcus identified in the latter case. This tattooist voluntarily ceased practice and eventually resumed practice once he was able to demonstrate adequate infection control procedures to an infectious disease specialist.12
There are only two other recent cases identified in the literature relating to complications of Samoan tattoos, both published in New Zealand. These are unique cases linking traditional tattoos to Diphtheria,13
an acute bacterial illness caused by toxigenic strains of Corynebacterium diphtheria, and Sporotrichosis,14
a fungal infection caused by the dimorphic organism Sporothrix schenckii. Although Hawai‘i is the home of the largest Samoan population in the United States, our literature review revealed no published case reports in this state. Similar to the published cases we have just reviewed, the tatau
process in our case was performed at the private residence of a local tufuga ta tatau
. It is likely that bacterial pathogens were introduced through use of non-sterile instruments or improper sanitary techniques.
Given the resurgence of traditional tattoos in New Zealand and the series of related pyogenic infections, bylaws have been formulated by the Manukau City Council to specifically address these issues.15
These bylaws have been amended to include standards for cultural tattoo artists that aim to prevent transmission of diseases. According to these regulations, a tufuga ta tatau
is required to obtain a permit to practice and demonstrate proper sanitation techniques before, during and after tattooing. In the state of Hawai‘i, the Department of Health has set forth minimum requirements for the safety and protection of public health.16
However, the licensing and sanitation requirements do not apply to culturally significant tattooing practices.