In this section, we will focus on understanding the physiology of tattoos. In this way, we will be better equipped to advise the clients on the various options to fade their tattoos. Also, this will help us understand how the fading techniques, currently available, work and how to use them in order to “remove”, or most appropriately, “fade” them effectively according to the client’s desires.

Figure 1. The Tattoo is an aesthetic drawing purposely made in order to reside permanently on the skin throughout the person’s life.

Figure 2. The tattooing process is relatively simple. It consists in injecting the tattoo pigments into the dermal layer.

Figure 3. Once the tattoo has healed the picture loses its original brightness. This is because the tattoo is visible through the thin epidermal layer. If the epidermal layer is removed, exposing the dermal layer, the original brightness is restored.

Figure 4. When the tattoo has just been made the initial ink location is both in the epidermis and the dermis, the area is essentially an open wound. Over time the scabbing process will take care of gradually removing the residual pigments form the epidermis. In a month's time, only very few residues of ink will be left on the epidermis. Once the area has healed completely the tattoo pigmentation will only reside inside the dermis and it will be visible through the epidermis.

Figure 7. This in an infection at its onset. It is noticeable how the area is red at the border of the wound caused by the tattoo work. If treated immediately this types of infection may not jeopardise the tattoo end result after healing.

Figure 8. In this picture, we can see the dire immediate consequences of an infection caused by poor after-care after a normal tattooing procedure. This particular infection was being cured, however, it was still present at the time the picture was taken as proved by the redness of the borders of the affected area. The redness at the borders is an example of an infection induced inflammation.
- Redness. The area starts to redden and the redness may include the tattoo work itself and the edges too. The redness of the edges feathers out and it spreads further as the infection worsen over time if not treated properly.

Figure 9. Redness can be a symptom of an inflammatory infection. We can see how the inflamed area peels off.
- Swelling. It is normal for a tattoo to swell during the first 48 hours after the tattoo as being drawn, however, if the swelling increases over three to four days instead of decreasing, or begins to extend past the tattoo a fair distance, this is likely a sign of infection.
- Heat. An infected tattoo might feel hot to the touch. While it is normal for the tattoo to feel warm, especially during the first 48 hours, it should not feel very hot and the heat should fade away on its own accord. If it is infected, the whole tattoo and/or the area around it may feel hot to the touch, and if may also feel as if there is heat radiating from within the tattoo itself.
- Discharge. During the first 48 hours after the tattoo has just been drawn a slights discharge and some bleeding can occur and this is normal. However, if this continues or worsens after the first 48 hours it can be a clear sign of infection. The infected tattoo often has a slimy discharge oozing from them in various places; this may appear as a clear fluid with a golden colour or a thick yellow-green goo that sits within the tattoo. You might also see pus (white, yellow, or green).
- Odour. This a sure-fire sign that your tattoo is infected. Often the discharge from an infected tattoo will have a nasty smell or odour. The smell increases in intensity as the infection spreads or worsen.
- Pain. If you're experiencing mild or extreme pain that increases over the 3-5 days after your tattoo or has sharp, shooting pains from within the tattoo itself, it is likely an infection.
- Blistering. Blistering may also be a sign of infection, and it can occur on top of the tattoo, manifesting as red, raised sores filled with body fluids. If your tattoo is bubbly or bright red, then this is a sign of infection. This is not to be confused with the normal swelling occurring after the first 48 hours of receiving your tattoo, any raised areas should slowly level out and decrease to the height of the surrounding (non-tattooed) skin.
- Increased scab size. Due to abnormal levels of discharge, the scabs on an infected tattoo may appear thick and bulbous and have a yellow and green crust. This normally occurs when the infections are subsiding while the scabs are being formed. This is generally a better situation than the symptoms mentioned above.
- Fever and lethargy. This is possible in advanced stages of infection, also this can occur if the tattoo is relatively large and infected. An infection over a large area will trigger the natural feverish body reaction, which is designed to help the body combat bacterial infections. If you have a fever or feel lethargic and these symptoms are unrelated to other illnesses, then it's likely your body is working overtime to fight the infection coming from your tattoo. If you experience any of the symptoms above, fever is one of the surest signs of infection, even if your temperature is only slightly elevated. In fact, even a slight elevated temperature can be symptomatic of serious advanced state of a inflammatory skin infection. Skin infections rarely lead to high temperature fevers.
- Redness or streaking. This is an extremely severe case of an advanced stage of infection. As we have seen previously, if the tattoo or the skin around it is extremely red, you likely have an infection. If you see thin red lines radiating from your tattoo, you should go to the doctor immediately as streaking can be an early sign of blood poisoning.
- Stage one, healing the open wound. Most delicate part of the process, this is when an infection or diseases can be contracted through the open wound.
- Stage two, scabbing or peeling process.
- Stage three, pigments resettling.

Figure 12. Fresh tattoos can bleed and weep like any other open wound which requires healing. In this picture, we can see a fresh tattoo slightly bleeding and weeping.

Figure 13. This picture serves to show the immediate effects of the tattooing process. Tattooing involves not only deliberately causing a wound inside the dermis, but also impregnating the dermis with the ink necessary to make the drawing requested by the client. Sometimes swelling can be caused by both the injury caused by the tattooing needle and the dermis reaction to the new substance injected into the dermis.

Figure 14. The fresh tattoo is an open wound that requires healing. The scabbing process usually sets on the third or fourth day after the tattoo has been drawn, provided that the area has not become infected. During this period avoid the use of any product not expressedly recommended by your tattoo artist as using unsuitable products on an open wound can cause unnecessary complications.

Figure 17. Tattoo wrapped in cling film for protection. This is usually done the first night after the tattoo is done to prevent contact with the bedding. Keeping the tattoo wrapped in cling film for too long d is detrimental as it creates the moist conditions for bacterial proliferation and hence infection. However, it has been found that during the first-night sleep the bandaging of the tattoo in cling film is more beneficial than detrimental.
- Do not apply any product not explicitly recommended by your tattoo artist as doing so especially during the healing phase (stage one) of the healing process could seriously jeopardise the tattoo work.
- Do not apply petroleum based skin products to your tattoo.
- You can shower, but you may not soak your tattoo for 2 weeks. No swimming, soaking or hot tub.Avoid swimming. In the swimming pool, Chlorine can leach colour and dry out the still tender skin around your tattoo. In the sea, the salty water could have undesirable effects on your tattooed area. Not hot tub.
- Do not wear tight, abrasive materials, jewellery, or shoes that rub against your tattoo.
- Do not let anyone touch your tattoo unless they wash their hands.
- Don't soak in the tub. This can allow bacteria to penetrate the unhealed needle wounds.
- Avoid exposing your new tattoo to direct sunlight. This can lead to fading and you could easily burn the unhealed skin.
- Do not pick at your scabs or scratch/rub your tattoo.
- Beware of gym equipment, wash it well before using it.

Figure 21. Keloidal formation caused by a simple tattooing. Every client should be warned in advance of the likelihood of developing Keloids before carrying out any tattooing.
Allergic Reactions to tattoos are quite common and there are different types of allergies that can be caused. Most often it is advisable to perform a patch test to determine whether your skin is too sensitive for the tattoo inks prior to actually getting it, but it may not always be a sure way of knowing. The main issue in order to prevent allergic reactions to tattoos is that, even if all ingredients are stated in the pigments packaging used, no one is always aware of all his/her possible reactions to each specific agent used in the tattoo colours or their mixture.

Figure 22. Example of an allergic reaction to the tattoo pigments. Swelling occurs in the tattooed areas only.
Allergic reactions have occurred with some of the many metals put into tattoo inks, nickel is one of the most common metal allergies. Others have reacted to the mercury in red cinnabar, to cobalt blue, and to cadmium sulfite when used as a yellow pigment. Some inks were found to have high levels of lead, some contained lithium, and the blue inks were full of copper. The long-term health effects of sustained allergic reactions to tattoos are still unknown due to the lack of regulation, testing, and long-term studies
Phototoxic reactions do occur, though not very common, considering the number of people who get tattoos done every year, where phototoxicity means having a reaction on exposure to sunlight. Inflammatory reactions caused primarily by the inks appear as swellings and red rashes which generally occurs for everyone and is expected to disappear within 2 to 4 weeks with proper attention and care.
Dermatitis caused due to allergic reactions to pigments is characterized by inflamed skin rashes and by the affected area becoming scaly or flaky. These allergic reactions do not always occur immediately after the tattoo has been applied, sometimes the effects can be delayed by months, even years. Itchiness and red bumps which can be caused due to changes in weather or body temperature often occur which will probably require a visit to your dermatologist or antibiotics.
Granulomas is a collection of immune cells known as histiocytes. Granulomas form when the immune system attempts to wall off substances it perceives as foreign but is unable to eliminate. Since tattoo ink particles are foreign material, granulomas can develop around or inside the tattooed tissue. Apart from granulomas, enlargement of the lymph nodes have also been reported as a side effect of tattoos. The pigments used, leak into the bloodstream, accumulating at the lymph nodes causing painful swellings in these regions. The major cause of concern due to these inflammations is the misdiagnosis of melanoma. In patients with cancer risks, a Radiologist is often unable to distinguish between the ink staining in the lymph node and the abnormal tissue growth.
- Haematomas are bruises that can occur due to the puncturing of a blood vessel during the tattooing process.
- Keratoacanthoma is a skin tumour characterized by a dome-shaped inflamed skin which gradually increases in size and its developments risks increase with tattoos.
- Hyperkeratosis which is an excess growth of keratin in hair follicles are all examples of abnormal growth whose occurrence also will depend from person to person and also the tattoo artist.
- Hyperplasia can also occur, hyperplasia is an organ enlargement due to abnormal cell multiplication.