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Micropigmentation (tattooing)
Micropigmentation (tattooing)
The use of micropigmentation, or tattooing, can be a good option for camouflage in patients with stable and localized vitiligo. Its use was first reported for the treatment of vitiligo by Halder et al. in 1989.66 This treatment involves the insertion of pigment into the dermis using either manual needles or electrically powered devices, such as tattoo guns or pencils. These devices typically have multiple stainless steel 25-gauge needles that are spaced about 0.3 mm apart, with adjustable speed and depth of penetration.12 The ideal depth for pigment placement is in the upper papillary dermis, which is approximately 1 to 2 mm deep depending on location. If the depth is too superficial, extrusion of pigment occurs, and if the pigment is placed too deeply in the dermis, it is cleared by macrophages, leading to an unsatisfactory appearance. Pigment may also migrate to regional lymph nodes, leading to fading of the tattoo.67
The main pigments utilized for tattooing include titanium dioxide (white), cinnabar and mercuric sulfate (red), iron oxide (black, camel yellow, light brown, and dark brown), and cadmium sulfide (yellow), which are available as powders.68 These are often blended using isopropyl alcohol, NS, water, or glycerin prior to tattooing to achieve the correct consistency and color that matches surrounding skin. The area to be tattooed is then marked and anesthetized using 1% to 2% lidocaine with epinephrine to achieve uniform penetration. A thick layer of pigment is then applied to the skin, which is stretched prior to needle insertion. An angle of approximately 45 degrees is utilized to improve visualization of pigment deposition after insertion. The area is then dressed with a layer of antibiotic ointment and a pressure dressing. Multiple sessions may be required to achieve proper color match.12,67,69
This procedure has achieved good results in mucosal and gingival areas as well as the nipples, and may be used in areas traditionally more resistant to medical management such as the fingers, wrists, elbows, and ankles. Optimal results are seen in patients with darker skin types.68 However, there are many drawbacks associated with this procedure. Risks include reactivation of herpes simplex virus, secondary bacterial infections, ecchymoses, edema, and crusting. Transmission of blood-borne diseases, such as HIV, Hepatitis B, and Hepatitis C can also occur. Risk of infectious disease transmission can be nearly eliminated through the implementation of sterile technique, as well as sonic cleaning and autoclaving of the instruments and tattoo pigments prior to every procedure.70 Allergic responses to pigments, including contact dermatitis, photoaggravated reactions, and granulomatous reactions are also possible.71
Postprocedurally, issues with color match may arise. Superficial penetration of pigment can lead to a faint appearance of the tattoo, while deeper penetration into the dermis can result in blue discoloration. Migration of pigment to the lymph nodes can also lead to fading of the tattoo. As such, periodic touch-ups may be required to maintain the original color. Another possible complication is oxidation of tattoos containing metal oxides, resulting in a black appearance that is very difficult to remove.
Tanning of normal skin in summer months can also lead to contrast between the tattoo and surrounding skin. Finally, micropigmentation can result in koebnerization, creating a cosmetically unacceptable appearance.67,71
Although micropigmentation can be used for camouflage of vitiligo lesions, it is not generally recommended due to color variations over time, the need for re-application, and the possibility of koebnerization. However, if a patient does decide to pursue this option, they should seek treatment with an experienced medical tattooist to avoid adverse events and dissatisfaction.