Derm-it Trotter! Don't Swear About Skincare.
Feeling frustrated or overwhelmed with everything skin? Does the skinformation overload make you want to swear about skincare? Join Dr. Shannon C. Trotter, board certified dermatologist, as she talks with fellow dermatologists and colleagues in skincare to help separate fact from fiction and simplify the world of skin. After listening, you won’t swear about skincare anymore!
Derm-it Trotter! Don't Swear About Skincare.
Think Before You Ink: The Science Behind Tattoos
Ever wonder how a tattoo becomes part of you for life? We sit down with board-certified dermatologist and associate professor Dr. Walter Liszewski to break down the science, safety, and art of tattooing—from how ink settles into the dermis to what really happens during healing, fading, and removal. He shares what matters most: finding a reputable artist, spotting real hygiene, and understanding how regulations differ across states.
We also explore tattoo reactions and skin health, from red-ink allergies and pigment-holding macrophages to what lymph node staining actually means. Dr. Liszewski explains when skin conditions like psoriasis, vitiligo, or sarcoidosis should shape your tattoo choices, and how medical tattooing—like areola recreation or scar camouflage—can restore confidence. Whether you’re getting your first tattoo or removing one, this episode helps you make informed, skin-smart choices about your ink.
You would caution them or warn them about or just the general health risks about where they might go to get a tattoo.
SPEAKER_00:Yeah. So the first thing that I tell people is to make sure that most pigments nowadays are large organic molecules. But strangely enough, the red ones still tend to be the most allergenic. In areas of trauma, we can sometimes get skin cancers that appear, something called the keratoacanthoma. Those are well established. The reality is that we know about a third of all Americans have at least one tattoo, and we're not seeing exceptionally high rates of malignancies of cancers.
SPEAKER_01:Welcome to Dermot Trotter, Don't Swear About Skin Care, where host Dr. Shannon C. Trotter, a board-certified dermatologist, sits down with fellow dermatologists and skincare experts to separate fact from fiction and simplify skincare. Let's get started.
SPEAKER_02:Welcome to the Dermot Trotter Don't Swear About Skin Care podcast. So exciting topic today. We're going to talk with Dr. Walter Lizuski. He's an associate professor at the Department of Dermatology at Northwestern University, board-certified dermatologist who actually loves to talk about tattoos. So welcome to the podcast.
SPEAKER_00:Thank you so much for having me. I appreciate it.
SPEAKER_02:It's great to have you here with us, Walter. So, first thing everyone's going to want to know do you have a tattoo? So we're hoping to get a juicy story here.
SPEAKER_00:Yeah, I have no tattoos whatsoever. I love tattoos. I think tattoos are cool. And I think tattoos are very similar to a lot of what we do in dermatology. You know, we do a lot of body modification in dermatology. Even if we don't think about it, filler, Botox, resurfacing lasers, there are things we could do to help people modify their appearance. And for me, I don't think tattoos are any different.
SPEAKER_02:So what you're saying is there's hope for the future. We could actually be maybe getting you a tattoo one day. Maybe we could do a live stream podcast.
SPEAKER_00:It could happen across collaboration. This is the thing. But you know what's interesting? There's a study that I did a couple years ago. And basically what we found out is that once you're above the age of 23, the likelihood that you regret a tattoo is very, very low. So if I were to get a tattoo, I probably would not regret it.
SPEAKER_02:Well, that's a good point. I will tell you, full confession, I do have a tattoo. My friend and I, 18 years of age, best friend, went and got matching Daisy tattoos. So still carrying this day, a little bit bond. Don't regret it, but definitely was an experience. So I can speak to the body modification, the pain, the fun, the excitement, and just the freedom. But definitely get that. Because I think tattoos, like you said, important for society. A lot of people don't realize that, like, how does a tattoo even work? Do you mind kind of explaining like how that's even possible to put pigment that's essentially no permanent in the skin?
SPEAKER_00:Yeah. So we have two parts to the skin. The top layer is called the epidermis, and the lower layer is called the dermis. So when you get a tattoo, the tattooist applies ink on the skin, and they take a needle that pushes the ink through the layers of the skin into the dermis. Now, as the tattoo matures, the that pigment will stay in what are called dermal fibroblasts or in dermal macrophages, which are a type of immune cell. And what happens is that when you get a tattoo place, that pigment stays in a dermal macrophage. And when it dies, it passes the pigment on to a new macrophage. So basically, it's this incredible story over a lifetime. Cells die off, but before they die, they pass the pigment on to a new cell, and amazingly, our tattoos stay in place. Now, after the uh tattoo is placed, there's an initial healing phase of about a month, and excess pigment will either be pushed out through the epidermis, and that's why tattoos will oftentimes peel or shed or crack. But some of it is absorbed into the blood and it's excreted through the urine or through the feces.
SPEAKER_02:That is really cool. So it's kind of like passing something on to the next generation, you know, like a good story, a good memory, or good tattoo.
SPEAKER_00:Yeah. It's amazing that it that how our body's able to hold on to this pigment, and it's the seamless continuation.
SPEAKER_02:It's kind of fascinating. Now, I think a lot of people are out there, okay, that's maybe like the classic tattoo you think of. You go to your local tattoo artist or tattoo shop. How does that vary from, you know, I hate to call it in this way, but the tattoos somebody might have gotten in prison or the military back in the day that are a little bit more amateur in style, or maybe even versus like a henna tattoo that we'll see some people get culturally, that's very important to them.
SPEAKER_00:Yeah. So there's a couple different things. So tattooing as a societal or human form of expression goes back tens of thousands of years. When you look at mummified bodies in the Andes, when you look at, let's see, who was a gentleman who died in a glacier in Switzerland thousands of years ago, all of them had tattoos. So tattoos are a huge part of human expression, and it's not really a new phenomenon. There is a distinction nowadays between what we call scratchers versus true tattoos. So a true tattoo is done by a tattoo artist. They have training, they've done an apprenticeship, and they operate out of a tattoo parlor where they usually will have some degree of good sanitary procedures. A scratcher is someone who's an amateur tattooist or a tattoo artist who works outside of a conventional parlor. And so that could be done in someone's basement, it could be done in prison, it could be something that high school kids do in their bedroom with a needle and some ink. There's a variety of ways that these can be done. But for all of them, there are differences in terms of the final appearance. When a scratcher works, they may not have all of the training to make sure that they're adequately tattooing, that they are getting the right depth, that they're not overworking or underworking the skin. And that's why a lot of amateur tattoos tend to fade with time, because the density of ink is not as good as, say, one done by a professional artist who has years and years of training and knows how to work with the skin. Things like henna tattoos are temporary because instead of getting into the dermis, they stay on the top layer of the skin, the epidermis. And as our epidermis grows out over a 14 to 28 day period, that ink will be pushed and sloughed off.
SPEAKER_02:So cool. And you're right. Like I think this is so important, and people understand like the variations and just culture how it's important for all of us. Because I think now, I mean, tattoos have become a little bit more mainstream, right? Like, I mean, I feel like sometimes it's more common. I do a lot of skin exams, and it's more common to find a tattoo, maybe even a hidden spot, or then sometimes not to, right? So if you, you know, had a patient come in talking to you, like, hey, you know, Walter, I'm thinking about getting a tattoo. What do I need to think about? Are there any like things that you would caution them or warn them about, or just the general health risks about where they might go to get a tattoo?
SPEAKER_00:Yeah. So the first thing that I tell people is make sure that you're going to a legitimate parlor. Make sure that um that depending on where you live, there may be different levels of licensure. Some states do not license tattoo artists at all. There is no state tattoo license in many states. That's scary. That's scary. Which is scary. And in some states, one of the big ones is Arizona, that I usually kind of call out. Um but the but but but then you have states like Massachusetts or Minnesota, which are very tightly regulated. And so it's not just that you have to have a license, there are periodic inspections. Um, you have to have aftercare instructions that are reviewed. That makes sense. So there some states have a lot of regulations. Now, even if a state doesn't license a tattoo artist, that doesn't mean a county or a municipality won't. So sometimes what happens is the regulation isn't on a state level, it's on a local level. And in some states, you can have multiple levels of organization where it's state, county, and municipal codes in terms of how a parlor has to exist. Now, some things in medicine that we think of as being standard aren't necessarily always requirements. Washing your hands, wearing gloves, making sure you have clean needle disposure. Most good tattoo artists will have those in place, even if they're not explicitly mandated by their local authorities. But it is important to realize on paper, those are not always mandated in all jurisdictions. So number one, make sure you're going to someone who washes their hands, um, wears gloves, and you know, has needle disposal. That's really, really important. Number two, don't be intoxicated when you get a tattoo. Um and it's interesting, you know, I did a study once looking at um tattoo uh sort of demographics, and I gave it in New Orleans where I did med school. And in New Orleans, you know, you're in the French quarter, you're giving people a survey on tattoos. People are, you know, very open, they're on vacation, they're really excited. And I believe it was about a quarter or one-fifth of all of our patients who we looked in this trial were intoxicated when they got their tattoos. And I remember presenting this at a tattoo conference, and all the tattoo artists were horrified. And I'm like, this is good. Like, yeah, they they they know you shouldn't be like tattooing drunk people. And they're like, no, no, no, it's not that. Drunk people bleed too much. That's the problem. That is what Yeah. I mean, there's just a consent component too, obviously. Yeah, if someone comes in clearly uh intoxicated, they're not going to do that. So, number two, think about what you want to do and meet with the artist and make sure you feel comfortable with what their approach is. Because not every artist does the same design. Some are really good with a watercolor style, some just do Japanese style, some do very impressive 3D, some do portraiture. So understanding what you want and what they can they can do is really, really helpful. And then the third thing is decide what colors you want. When it comes to reactions and allergenicity, the main color still is red. If you look in dermatology textbooks, you'll read about um cadmium and cinnabar, which is mercury. We haven't used those for decades in the US. So unless you're like illegally importing inks, those heavy metals aren't even being used, even though they're listed in the textbooks. Most pigments nowadays are large organic molecules, but strangely enough, the red ones still tend to be the most allergenic. So if you're worried about there being an allergy, I recommend sticking to just black because that's just ground up charcoal. It's fairly inert.
SPEAKER_02:Okay. And you mentioned too the regulation piece, if somebody, and again, it may vary per state, you probably know this. If somebody's just wanting to know if they are following guidelines or things that should be happening in their state, do they have to put any sort of like designation or sign or something? Like, how do patients know that this is a place that's really following the rules? Is there a way for them to find out or a certification nationally or anything that could help guide them?
SPEAKER_00:Yeah. So it really varies from, again, um location to location. In general, um, for standard hygiene practices, if a parlor is required to have a licensure, usually those will be posted. If there are requirements that the tattoo artist has passed blood-borne pathogen training, a lot of times that has to be posted. It really varies from state to state. So have a conversation with your artist. Ask them, you know, are you regulated? What's kind of your sanitary procedures? And tattoo artists, the thing you have to understand is tattooing is a lot like cosmetic dermatology. You're only as good as your reputation. And if you do bad work, people are going to know you do bad work. Tattoo artists take years and years of training. I think the general public doesn't realize that in order to become a tattoo artist, you have to do an apprenticeship that may take two, three, four, five years. Plus, you have a background in art. Tattoo artists care tremendously about their clients, making sure they don't have complications and that the work they're putting out there is the best reflection of what their abilities are.
SPEAKER_02:And if somebody has psoriasis or eczema, do you ever talk about, you know, some concerns maybe with potentially tattooing or something they might have to be on the lookout for? Because I know a lot of people are worried about that, could it potentially make a skin condition they have worse or cause it to flare?
SPEAKER_00:Yeah, that's a great question. So in in dermatology, we have a fancy term called kebnerization. And basically, in simple English, what's what it means is that for some people who have certain types of skin diseases, when they have trauma, such as from a cut, they may develop their skin disease at that location. So these include things like vitiligo, where you lose pigment, psoriasis where the skin becomes too thick, um, or other things like sarcoidosis or lycoplantis. In the literature, things like psoriasis really tend to not kevnize. So for the average patient with psoriasis, I tell them be very careful. Your psoriasis could show up where you get a tattoo, but the likelihood is low. For other diseases like sarcoidosis, though, I would encourage patients not to get a tattoo because the association of the disease showing up at sites of trauma is just a lot higher.
SPEAKER_02:Well, and I think probably the thing that's on everyone's mind, you've probably seen a lot of information out there, probably some misinformation, some that's accurate, it's just this potential kind of link between cancer and tattooing. Because obviously, you know, we talk about health, or we think about, you know, whether or not the place is regulated, are they following hygienic standards? But then could there be any long-term complications of potentially getting a tattoo, specifically looking into skin cancer and lymphoma? So, what do you think about what's being set out there, what data we actually have, and does it show if there's any true, you know, link between the two?
SPEAKER_00:That's a great question. So, one of the things we know is let's say you have a large tattoo on your left arm, okay? Um, and then you die and you have an autopsy and they look at your body, your lymph nodes in your left armpit, which is where the fluid in your left arm would drain into, are going to be the color of your tattoo. We know that if a woman has breast cancer and she has a tattoo on her arm and they have to remove a lymph node from her underarm, a lot of times many of those nodes will be stained with ink. Because when the tattoo is applied, not all of it gets stored. Some of it gets kind of absorbed into the blood or into the lymphatics, and it tends to drain tissues. So we know that the inks do get into lymph nodes, which is where our white blood cells live. And those are the cells that will cause a type of cancer called leukemia or lymphoma. The issue is that there's a difference between the types of tattoos and what these databases can do. So one of the other hats I wear is that I am a cancer epidemiologist, and uh I have an appointment in cancer epidemiology at Northwestern, and I do a lot of research with large data sets. Your ability to associate a disease with a particular finding is really contingent on how good is that data. So I want you to imagine you have a tiny, tiny little tattoo on the back of your hand versus someone who has their entire arm tattooed. They have a full sleeve. We can recognize that the amount of ink that that first person has been exposed to versus the second one is fundamentally different. The their magnitude is different. But a lot of times in these databases, they can't distinguish between small tattoo versus large tattoo. They also can't distinguish between which pigments were used. Maybe there's something very pro-cancer about certain yellow or green pigments, but not about black or purple. That's another thing that we don't know is that these databases can't really distinguish what the colors are. So we don't know how much of their body is covered and which inks are being used. And so in a lot of these uh more recent epidemiological studies that are trying to associate cancer exposure with leukemia or lymphoma, there's just a lot of missing data. And it's really hard to say that these are high-quality studies. I think they're interesting. I think there's something we should think about, but I'm not convinced yet that tattoos in and of themselves are associated with a higher uh risk of leukemia or lymphoma.
SPEAKER_02:And on the skin cancer front, what do you feel like it's showing there? Because I know that's a question we often get asked as well.
SPEAKER_00:Yeah, um I I'm not convinced either. Um part of what's challenging is that in areas of trauma, we can sometimes get skin cancers that appear, something called a keratoacantoma. Those are well established. Um it's hard to tell do other things like basal cell, squamous cell, or melanomas have higher rates in tattoos. I just haven't seen any large-scale high-quality studies that make me concerned enough to warn patients about that.
SPEAKER_02:So kind of bottom line, you feel like, and I feel like this is a lot of us tell patients, if they come in and say, hey, I was thinking about getting this tattoo, but you know, I read on Dr. Google it's gonna get cause me to get leukemia, lymphoma, or skin cancer. Your response would be not enough data to really suggest that we're looking at things, but at this point, I'd still be comfortable with you going forward with a tattoo, or how would you kind of explain that to a patient who sort of has the temp?
SPEAKER_00:Yeah, so I'd basically say I feel comfortable with you doing it. The reality is that we know about a third of all Americans have at least one tattoo. And we're not seeing exceptionally high rates of malignancies of cancers in in these populations. So I think if there is an association, it's probably a very weak and very low association. One of the other things to be aware of, the FDA doesn't regulate any of this. There is no regulation of any of this. You and I, Shannon, can create our own tattoo ink company.
SPEAKER_02:Ooh, we've got a plan.
SPEAKER_00:We have a plan. No one's gonna regulate it. We don't even have to sterilize the ink. That's kind of there's not like good, there's not like good manufacturing processes here because it's not really meant for human consumption. And so it's this sort of gray area, although people are using it off label for tattoos. So um the point of it is that the public assumes that the government is regulating this, that we know what's in the inks, that we're making sure that there's not bacteria in the inks. And the answer is none of that is happening. The FDA has authority to step in if there are outbreaks. So if there's a bad batch of ink that's causing severe infections um across the U.S., the FDA has legal authority to step in and issue a recall. But currently, the FDA does not have a strong legal authority to regulate what's in tattoo inks, let alone the manufacturing or quality control process.
SPEAKER_02:That's a great point because there you're right, there is that assumption that people just think that exists. And in a you know, a type of area or a market where things are not regulated, obviously some things can go unnoticed, but it's important for consumers to be aware of and for us to tell our patients that there are things to look for, but you know, this isn't regulated as tightly as you might suspect. And I know we talked a little bit about that skin cancer piece. One of the questions I get asked, you know, all the time in particular is if somebody has a scar, can I tattoo over this? And you know, first thing I'll talk with them about, well, sometimes you know, scars don't always take up the tattoo pigment as well. You're gonna have some texture. But then of course, you know, if they've had a melanoma history, I often caution against that because of looking for you know recurrence or repigmentation. Do you kind of share those sentiments with scarring for your patients too, where you get concerned, you know, that they might want to tattoo over that?
SPEAKER_00:Yeah. So if it's definitely over a uh a previous cancer, that's that's that's a pretty clear, I'm not going to encourage you to do that. That being said, for scars, uh many tattoo artists who work with scars are really talented and they can sometimes get really great results, either for a cosmetic tattoo, like in some sort of design or shape, or even medical tattooing where they can actually fill in the scar to make it appear more similar to the background skin color. Um, so a sort of camouflage tattoo. So those are really great options. And there's a lot of really great options for medical tattoos. Things like severe alopecia areata, you can tattoo hair on the scalp, you can tattoo eyebrows, uh, things like nipple reconstruction after breast cancer surgery, some patients with refractory vitiligo, tattooing can be really, really helpful. And if done by the right person, the results results could be outstanding.
SPEAKER_02:I would agree that I mean these folks are definite artists, especially I've seen nipples, amazing the pressure, the elevation, the dimension that they can provide people. I must confess, I get microblading, a form, you know, of tattooing as well, which is a little bit you know different from what we've talked about, but it kind of gives the connect or crossover, you know, with permanent makeup and tattooing. And so I know you've talked a little bit about that for people to kind of understand the value, like you talked about, that we can use medical tattooing to help and even kind of in the you know aesthetic cosmetic space. What are your thoughts on the medical, you know, kind of in the, you know, the standpoint of makeup and permanent makeup and how it crosses over with tattooing?
SPEAKER_00:Yeah, so you would think permanent makeup and decorative tattoos would be similar, and in many ways they are, but they're also very different. Um, the biggest distinction is there are some tattoo artists who do permanent makeup, but in general, most people who do permanent makeup don't have the same level of training that a tattoo artist does. So a tattoo artist, before they're even able to pick up a tattoo gun, has done apprenticeship work for months and months. They've done training. Um, there's a study we have coming out soon looking at permanent makeup, and the average amount of training for someone to do a permanent makeup course is somewhere between six and eight hours. So on Saturday, you and I are gonna go to a you and I are gonna go to a strip mall. We're gonna do a six-hour course, and we're gonna learn how to do eyebrows. That's that's fundamentally different than someone who wants to do true decorative tattoos that takes years of training. And so there's always a little bit of friction between permanent makeup artists and tattoo artists. Now, the people who do permanent makeup, the people who do a lot of it can have really great results. Um, but it's important for consumers to know that the training is a little bit different um in terms of how comprehensive it is.
SPEAKER_02:Yeah, and unfortunate, the gal that does my microblading is also a tattoo artist, so she has a nice overlap for her business. So I get the best of both worlds. Somebody with a great skill set, she's had pretty extensive training, and I know we can't see it, but the microblading is pretty impressive that she does.
SPEAKER_00:You guys do well, yes.
SPEAKER_02:Instagram, you'll be able to see the whole video. We actually videotape the entire thing, the process for people to see it. Because I I'm one of these dermatologists. I'll tell I'll tell Walter, I'll tell my patients do these things, but then I'm too scared to do it myself. And I'm like, you know what? I can't be a hypocrite anymore. I gotta try to see what happens, see what happens. So the last few minutes we have then, you know, for people that may have chosen to get a tattoo in the true sense, and maybe they are the few that regret it. They decided to do this and thinking, all right, I made a mistake here. You know, what are the options to actually have a tattoo removed?
SPEAKER_00:So let's talk about the options you should not do. Do not do the home kits. Because on Amazon, you can buy acid to put on. You can basically get uh different grits of sandpaper to basically kind of uh physically exfoliate the dermis out of your skin. That can lead to severe infection. So don't do that. Um the the two major ways that we approach removal, the historical way was with cutting the tattoo out. If it's small enough, you can cut it out, or if it's larger, you can kind of cut it out in pieces, and then you let the skin stretch, and then you cut more out. This is a great option for people who don't want to do a laser. The other option is laser tattoo removal. And there's a variety of lasers that will target the pigment in the skin for laser uh for tattoo removal. The downside to uh laser tattoo removal is that most people say it is more painful than the tattoo itself. And number two, it can take many, many, many sessions. So you may be looking at five, seven, ten sessions before you get complete resolution of the tattoo. And even then, there still may be either a little bit of faint outline from the tattoo, or if you're someone with slightly darker skin color, the lasers may also lighten some of your background skin color so that the skin is a little bit lighter and a little bit more noticeable where you had the tattoo.
SPEAKER_02:Wow. I mean, this has been really interesting. You know, I think people are gonna be surprised from the dermatology perspective. This is something we really talk more about with our patients and understand. I think it's a fascinating area for you to have this little you know level of expertise because we don't know a lot about tattooing, and it's something that we need to know more about. And I know our listeners out there want more about some people are considering getting a tattoo. So, from your perspective, I guess what I want to know if we're gonna get this tattoo. I've already got an idea for you. Can't see it on the screen, and I think I got it, but I think you should get the Dermatrotter logo tattoo. That's what you need to do, try right here on the arm. We can get you one of those, get it going. We'll get some temporary ones maybe to pass around next time.
SPEAKER_00:And that's actually that's actually not a bad idea to actually but I mean seriously though, um, we we've made really great advances with temporary tattoos. You can get them printed online. If you're some who's kind of like on the fence, get a temporary tattoo, wear it for a while, and see how it goes and see if you actually like it.
SPEAKER_02:That's a great idea. Great idea. Well, thanks again, Walter, so much for coming on the podcast. This has been a fascinating topic. We have to come back, talk more about some other aspects of tattooing because I know people love this topic. So thank you so much for coming on. I appreciate it.
SPEAKER_00:Absolutely. Thank you so much for having me.
SPEAKER_02:All right, and stay tuned, guys, for the next episode of Dermot Trotter Don't Swear About Skin Care.
SPEAKER_01:Thanks for listening to Dermot Trotter. For more about skincare, visit dermittrotter.com. Don't forget to subscribe, leave a review, and share this podcast with anyone who needs a little skincare sanity. Until next time, stay skin smart.
