Understanding the risks and how to reduce them can help you make informed, confident decisions before getting inked.

“Tattoos are a great way for people to express themselves,” says Walter J. Liszewski, MD, a dermatologist at Northwestern Medicine. “I am not against tattoos or permanent makeup. I just want people to be informed and safe.”

What are common tattoo complications?

Although complications are rare, they do happen. The most common issues include:

• Infections, including common bacterial types and less common types that can be harder to treat (such as mycobacterial)
• Allergic reactions
• Scarring or keloids
• Triggering or worsening of skin conditions like psoriasis, vitiligo or sarcoidosis

“Allergic reactions to tattoos tend to occur months to years after they're placed,” says Dr. Liszewski. “What happens is UV light breaks down the pigments into smaller pigments. It’s those smaller fragments that become allergenic.”

What causes tattoo complications?

Complications can result from several factors:

• Contaminated ink or equipment can introduce bacteria or viruses.
• Tattoo pigments may contain metals or allergens. Red ink is especially known for causing allergic reactions.
• Tattoos on areas with poor circulation, such as below the knees or on the genitals, are more prone to infection.
• Improper aftercare — like touching a fresh tattoo with unwashed hands or using contaminated lotion — can also lead to problems.

“Consumers themselves have a major responsibility to ensure proper healing of their tattoo,” says Dr. Liszewski.

How can you recognize an infected tattoo?

The telltale signs of infection include:

• Redness
• Warmth
• Swelling
• Tenderness
• Pus or drainage
• Fever or swollen lymph nodes

“If your tattoo is painful, hot to the touch or oozing, it is time to see a doctor,” says Dr. Liszewski.

How are complications treated?

Treatment depends on the type and severity of the complication:

• Mild bacterial infections may be treated with topical or oral antibiotics.
• Severe infections, such as those caused by mycobacteria, may require long-term antibiotics.
• Allergic reactions can be managed with corticosteroid creams or immunosuppressants.
• Scarring or granulomas (clusters of immune cells that form hard lumps in response to an infection) may require laser therapy or surgical intervention.

What is tattoo flu?

• Tattoo flu refers to flu-like symptoms that some people experience after getting a tattoo. It’s not an actual infection, but rather a short-term immune response to the trauma of tattooing.  Note: If tattoo flu symptoms are persistent, worsening or accompanied by signs at the tattoo site, they may indicate an infection and should be checked by a medical professional.
• Symptoms may include fatigue, chills, low-grade fever and body aches. These usually resolve within a day or two without treatment.

Are some inks safer than others?

Yes. Black ink is generally considered the safest and least allergenic.

“If you are worried about allergies, stick with black ink,” advises Dr. Liszewski. “It is also the easiest to remove if you change your mind later.”

Some pigments may contain metals like nickel or cobalt, which can trigger skin issues or interfere with medical imaging.

“Historically, red inks have been the most allergenic, and red inks continue to be the most problematic,” says Dr. Liszewski. “The other thing that's challenging is that a tattoo ink is multiple colors. For example, if you see a red tattoo, it's probably a blend of red, white and maybe some orange. It’s rare for an ink to be made up of one single pigment.”

For that reason, you may react to an orange tattoo, but it's not because of an orange pigment. It's because of a red pigment that's blended into it.

What about permanent makeup?

Permanent makeup carries similar risks to decorative tattoos. About two-thirds of the pigments used in permanent makeup are the same as those used in body tattoos. However, many pigments in permanent makeup fade faster and may contain different additives.

Before getting permanent makeup, Dr. Liszewski says, “Ask your provider how long they have been doing permanent makeup and to see a portfolio of their work.”

Also, be aware that training standards vary from state to state. While tattoo artists often complete years of apprenticeship, some permanent makeup providers may only take a short course. To find specific licensing information for your state, consult your state’s licensing board or department.

How to Reduce Your Risk of Complications

• Choose a licensed, reputable artist.
• Make sure your artist sterilizes their equipment and wears disposable gloves.
• Avoid getting tattoos on high-risk areas like below the knees or on the genitals.
• Ask about ink ingredients and be aware of known allergens, such as metals, pigments and preservatives like formaldehyde. You can also check for ink recalls at any time.
• Follow aftercare instructions carefully. This includes:
  • Using pump soap and lotion. Pumps are more hygienic than bars of soap or tubs of lotion that are touched repeatedly.
  • Washing your hands before touching your tattoo.
  • Avoiding sun exposure and swimming while your body art is healing.