Skin Anatomy

Main reference for Anatomy taken from https://openstax.org/details/books/anatomy-and-physiology-2e

Tissue Organization

There are over 200 different cell types within the human body. The human body is organized into an
organizational hierarchy from an atomic level up to the entire organism. Cells are organized into groups
called Tissue. There are 4 categories of Tissue:
• epithelial
• connective
• muscle
• retinous
Each category of tissue has a specific function or job within the body. When all tissues are functioning
properly together it is called homeostasis. The study of tissue under a microscope is Histology. Tissue
is grouped together into Organs, organs are grouped together into organ systems. The skin and its
accessory structures is an organ system called the Integumentary system. It is the largest organ in the
human body and makes up approximately 16% of body weight.

Epithelial Tissue/Epithelium
The medical term for cells that cover is an epithelium. The body is covered in epithelial cells on its
exterior but they are also found in the lining of internal cavities and the covering of some glands.
Connective Tissue
Connective tissue binds cells together and is used to support and protect organs. For example, the skin
is connected to the fascia of the muscles using connective tissue.
Muscle Tissue
Responds to stimulation (it is excitable) and provides movement. Muscle tissue is subdivided into three
types based on cellular structure – Skeletal, Cardiac, and Smooth.
Nervous Tissue
Allows for electronic signals to be passed all over the body from the brain. These are used for
communication and are also excitable.

Tissue Membrane

The sheet of tissue covering organs or organ systems is called a membrane. Tissue Membrane is very
thin and there are many different types of membrane within the body, all performing different
functions. Tissue membrane is divided into two types – epithelial membrane and connective tissue
membrane.

Connective tissue only contains connective tissue cells. It is used to surround organs or connect them to
other tissues and line joints. Epithelial membranes are a layer of epithelium cells that are attached to
connective tissue. E.g The mucous membranes inside the mouth are an epithelial membrane that is
connected to the lamina propria connective tissue underneath.

Skin is also called the Cutaneous Membrane. What we think of as skin is not the only point of contact
with “outside” of the body. The airways, digestive tract, and reproductive systems are all lined with a
type of epithelial cells. Epithelium is cellularly dense meaning there is very little material in its
composition that is not needed in its function.

The lowest part of the skin from the outside is the basement membrane. This membrane is made of
the basal lamina (made of proteins and collagen) which attaches the epithelium to the connective
tissue. The connective tissue is the reticular lamina. The two lamina together form each side of the
membrane. The epithelial layer is a physical barrier to the outside world and all substances must pass
through it to enter the body. All epithelial layers are avascular meaning they do not contain capillaries
or have blood flow of their own.

Epithelial Cells

The skin is made up of many different cells but what we usually refer to as “skin cells” are epithelial
cells. Epithelial layers are classified by both shape and number of layers of the epithelial cells inside.
The shape of the cells within the epithelial layer determines their function. There are three shapes
of epithelial cells:
• Squamous – these cells are flat and thin like pancakes.
• Cuboidal – these cells are square and boxy like a packing cube
• Columnal – these cells are tall and thin like a skyscraper

The cells in an epithelial layer can be as thin as a single cell. Delicate skin areas have less cells in each
layer and are therefore much thinner. The skin is a stratified epithelial structure that is made of many
layers that are both thick and thin depending on their function. Some of the layers are irregular and the
cells within each layer determines what the function of the layer is. The stratification process helps to
protect the lower cells from wear and tear. Each layer is named after the cell shape within it. The
stratified squamous epithelium is the most common type of epithelial layer in the body.

The Integumentary System

The skin provides an overall layer of protection for the body. It is multilayered (stratified) with various
structures held together by connective tissue. Deeper tissue is highly vascular with good blood flow
while the more superficial layers are avascular. The skin has sensory, autonomic, and sympathetic nerve
fibers within in. This means your body can respond both subconsciously, consciously, and with
movement to stimuli.
 The Epidermis
The epidermis is the topmost and outer layer of the skin and is a Keratinized Squamous
Epithelium. It consists of 4-5 layers of epithelial cells that are all avascular. Thinner skin has only 4
layers. The only places where your skin is thick enough to consist of 5 layers is the soles of your feet
and the palms of your hands. The 5th layer of skin is the Stratum Lucidum and it is located between
the Stratum Corneum and the Stratum Granulosum. Except within the Stratum Basale all cells
within the epidermis are a type of keratinocyte. Keratinocytes store and process keratin, a fibrous
intracellular protein which is hard and water resistant. The top layer of the skin is the Stratum Corneum
which only contains dead keratinocytes that constantly slough off to be replaced by more from the
anterior layer. Think of this as the layer that peels with a sunburn. The cells in the basal layer are
cuboidal epithelials and as they move towards the corneum they become squamous. A tattoo must pass
fully through this layer to be permanent as these skin cells will all eventually slough off and so will any
ink within it.

The Stratum Basale

Also referred to as the Stratum Germinatium as this is where keratinocytes are generated. It is the
deepest layer and is attached to the basal lamina which sits above the dermis. The basement membrane
connects the stratum basale using collagen fibers (connective tissue) to the dermis layer. This
connection is strengthened by dermal papilla protruding through the membrane from the most
superficial layer of the dermis below. The stratum basale is a single layer of cells thick but is
undergoing constant mitosis and producing new cells.
Melanin
There are two other types of cells found in the Stratum Basale. These are Merkel Cells and
Melanocytes. Melanocytes are responsisble for producing Melanin which protects from UV
damage and also produces the pigment that causes skin to have color. There is more about
Melanin and Melanocytes under the section on Pigmentation and Fitzpatrick.

The Stratum Spinosum

This is named after the “spiny” structures that appear under a microsope in this layer called
Desmosomes. Desmosomes interlock with each other which makes this layer especially strong. The
spinosum is 8-10 layers of keratinocytes thick. This layer contains Langerhans cells which release
glycolipids that make the skin waterproof.

The Stratum Granulosum

This layer is 3-5 cells deep and it is where the cuboidal cells begin to flatten out. This layer produces a
lot of keratin and keraohyalin as the “leftovers” from cell death. It is where the epithelial cells begin to
disintegrate and die before forming the next layer. In the hair and nails this layer is especially important
as Keratin is the main protein that provides both structure and strength, if the layer does not produce
enough keratin the superior layers will be weak and prone to damage or incomplete.

The Stratum Lucidum

This is a semi transparent layer that sits directly below the stratum corneum. It is found ONLY in
thicker skin (palms and soles). In this layer the keratinocytes are fully dead and have flattened out
completely. It is full of eleidin, the protein produced from keratohyalin breaking down.

The Stratum Corneum

The outermost and most superficial layer of the epidermis is also the thickest. This layer is 15-30 cells
thick. It is dry, dead, and acts as a thick protective layer to the cells and structure underneath. This layer
is dehydrated as there are no nutrients needed to keep cells alive. It provides a mechanical protection
from abrasion and microbes by being a physical barrier but also provides protection from dehydration
by preventing evaporation from the layers below. This is where dead keratinocytes shed and are
replaced from the stratum granulosum below. The layer is completely renewed every 4 weeks. While it
is suggested that cosmetic tattoos sit within this layer to be considered temporary the fact is that the
tattoo process is permanent and it is unlikely even with the gentlest hand that you can maintain a tattoo
fully within this layer and clients should understand that all tattoos are considered permanent.

The Dermis
This is the most important layer when it comes to tattooing. All ink must be within the dermis to stay
and not migrate. If the ink isn't in this layer it will slough off with the dead keratinocytes and if it
passes beneath this layer it is likely to migrate and cause blurring or ink creep. The dermis is the core of
the integumentary system. The dermis contains many supporting structures of skin function within it
including lymph vessels, nerves, hair follicles, and sweat glands. It is very vascular and full of blood
vessels.
The dermis has 2 layers of connective tissue made of elastin and collagen. The two layers are the
Papilliary Layer and the Reticular Layer. There is an indistinct border between the two which means
it can be hard to separate them on a cellular level. This is called the Dermal Junction and is where you
can find Rete Ridges and Rete Pegs. These protruding structures help to strengthen the connection
between the two layers and fit together like a jigsaw. The rete ridges fit tightly against the dermal
papilla in a wave-like pattern. These ridges can be seen with the eye in fingerprints but are usually on a
microscopic level.
The Papilliary Layer

The Papilliary layer is made of loose areolar connective tissue (nothing to do with breast tissue, simply
a similar name). This is the most superficial layer of the dermis and it joins to the stratum basale of the
epidermis. The layer is named for the dermal papilla which protrude into the epidermis. These papilla
has at least one capilliary within it to provide nutrients to the basale layer of the epidermis for mitosis.
The layer contains many blood vessels and lymphatic capillaries as well as nerve fibers and Meissner
Corpuscles which are triggered by touch.

The Reticular Layer

This is the thicker of the two dermal layers and is made of dense and irregular connective tissue. It has
a mesh like structure that is quite irregular in shape. The mesh is made of a combination of collagen
and elastin. The connective collagen fibers extend down from this layer into the hypodermis to provide
a strong anchor. These collagen fibers also help trap water to keep the skin hydrated.

Hypodermis/Superficial Fascia

This is the layer below the dermis. If your ink reaches this layer you will see migration. It is what
connects the skin to the muscle fascia below. It is technically part of the skin/Integumentary system
because it does not have a distinct border with the dermis. It is a very vascular tissue made of both
areolar tissue and adipose (fat) tissue. This layer functions as subcutaneous (below skin) fat storage that
helps with heat/cold regulation and as cushioning for the layers above. Your hormones are responsible
for where in the hypodermis your fat is stored.

Interestingly studies have shown that tattooed skin actually changes structure. It has a higher level of
fats called lipids and lower levels of certain proteins. The connective tissue is also a different structure
than normal skin and may lead to higher levels of inflammation.
 Accessory Structures of the Skin
The skin has many accessory structures within it and is also acidic on its surface. While these are not
necessarily important during the tattoo procedure they do play a part in the body's response to the tattoo
process. For example, during a tattoo when adrenaline and cortisone are flowing freely the sweat
glands are activated to help lower the body temperature that increases with increased metabolism. The
accessory structures also help to give the skin it's structure and also play a part in the healing process.
Without the accessory structures we would be unable to sweat, our skin wouldn't be able to have a
successful immune response and we wouldn't have things like body hair to help with regulating body
heat.

Sweat Glands
There are two types of sweat glands in the body. They are sudoriferous and eccrine. Both produce
different types of sweat during the tattoo process. The sudoriferous glands excrete sweat from the gland
up through the skin using a duct. The sweat they produce is different in content than that from the
eccrine glands. The eccrine glands are only found in the palms of the hand, the soles of the feet and the
forehead. In comparison they are coil shaped and release sweat by excytosis. This type of sweat also
contains antibodies and metabolic waste and is most important for thermoregulation.

Sebaceous Glands
These secrete the oil used to lubricate and waterproof skin. For people with oily skin these glands are
often overactive and produce too much of this oil. The amount of oil (sebum) produced can affect the
healing of a tattoo and can prevent a stencil sticking properly if it is not cleaned off first. The sebum
mixture produced helps to prevent water loss from the epidermis but is also primarily responsible for
acne and zits forming. These glands only become active after puberty. Sebum and keratin accumulate in
pores which can become blocked. This provides a breeding ground for bacteria which will then cause
inflammation and an immune response to the infection. (see additional section on skin diseases and
blemishes)

Hair follicles
Hair should always be shaved or removed prior to a tattoo procedure. The exception to this is PMU
because the process is much more delicate and it's important if the hair is there to be able to see the hair
direction. If hair is not removed prior to tattooing the hair may be pushed back into the follicle by the
tattoo process and potentially cause an ingrown hair or infection. Hair follicles are located in the dermis
and the sebaceous sweat glands also drain into the hair root sheath to express sweat.

Lymph Nodes
While the lymph nodes are not located in the skin itself the lymph vessels are. The lymphatic system is
part of our immune system and the lymph fluid that flows within it is a way for toxins and particles to
be filtered out of the body. It carries waste products and bacteria away to be destroyed or neutralized.
However, the lymph nodes can also trap these. It is not unusual for people to have swollen lymph nodes
after getting tattooed due to their immune response.
There is some evidence that connects Lymphoma and tattoos. Certain tattoo inks are banned in the EU
because of evidence that links certain pigments to lymph cancer. This is based on autopsy and biopsy
results that have shown certain blue and green pigment particles that are small enough to pass into the
lymph system but become trapped in the lymph nodes. Where a tattoo is near a lymph node it is likely
that the node will process some of the excess pigment. Certain inks do have higher levels of toxic
metals like copper and aluminum. MRI scans of these nodes often appear opaque and abnormal
because of the accumulation of ink and while they may not be cancerous it is impossible to tell without
a biopsy for sure.

Pigmentation and Fitzpatrick

There are many blanket terms used for the colors of skin. However your skin not only changes color
but also has both undertones and overtones. Understanding pigmentation and color of the skin will help
both determine the best colors that work with your clients skin tone and give you some foresight into
how the colors will heal and settle over time. Your clients skin tone and type will also determine how
well the tattoo procedure is likely to take and whether it may be more likely to need touching up.

Melanin and Pigmentation

Three factors will determine skin pigmentation – melanin, carotene and haemoglobin. When UV rays
hit the skin it is prompted to produce extra melanin. The mealnin in skin helps to protect cells from UV
damage and prevents folic acid breakdown. If broken or damaged skin is exposed to high UV rays the
extra melanin can become permanent. Scars will be darker if they are exposed to sunlight just as skin
that is still healing can become damaged if it is exposed to excessive sun.
There are two types of melananin produced by melanocytes in skin– Eumelanin and Promelanin.
Melanin affects how the color of ink in the skin will appear and understanding how it affects different
colors is essential in picking the right colors for your client. Colors should be chosen based on an
estimation of 30% of the natural skin color of your client plus the pigment choice. With this being the
case not all colors are suitable for all skin tones and results should be explained accordingly.
• Promelanin is primarily responsible for the “rosy” color of lips and nipples and is red in color
where
• Eumelanin is yellow and produces a black/brown tone.
Melanocytes are the cells that when damaged become Melanoma. (see additional section on skin
diseases)

The Fitzpatrick Scale (FTP/FSP)

The Fitzpatrick scale was created in the 60s to determine skin tone and it's response to UV light
therapy. With this in mind it is also extremely skewed towards caucasian and lighter skin tones. It is
still being developed for skin types that have more melanin and has been updated in the past few years
to include types 5 and 6. Skin types are classified from 1-6 based on their risk of burning and color.
Darker skin tones on the FSP have more dark melanin in them.
FP 1 is the palest tone which also has the most promelanin, red tones and freckles. Type 3 is the highest
type that will see freckles appear in the sun. Types 1 and 2 produce less collagen which means they are
sensitive, less likely to see scarring and usually have a blue undertone, are prone to sunburn however
they are more prone to conditions like Rosacea. Types 1 and 2 are also the driest skin tones. Type 3 and
4 are more susceptible to visible scarring and while they may still have a sunburn they also are more
likely to tan than burn. Types 4 and 5 have larger pores and often have an uneven or thicker skin tone.
They are more prone to inflammation and hyperpigmentation in scarring.
When tattooing skin the Fitzpatrick scale can give you both an indication of how the tattoo will heal,
what pigments will work well in terms of color, and also how that tattoo is likely to fade since you can
predict their sun exposure habits.
Determining Undertones
Determining the color and undertones of your client skin means knowing your color wheel and color
theory well enough to make an informed assessment. Not choosing the right shade will at best mean the
color doesn't show well or is too harsh while at worst the skin will give it a purple or green cast. The
color wheel is invaluable in giving you good choices for your designs and your clients skin color. The
most important part of figuring out your clients undertone is to know that opposite colors will
neutralize each other. For example a blue and an orange or a red and a green. This is especially
important on darker skin tones as the red or brown hues from the increased melanin will likely
neutralize blues and greens for this reason.

Skin tones are divided into 4 types: Light, Fair, Medium, and dark. If you're not sure where the client
falls on the Fitzpatrick scale you can simplify and use one of these to narrow it down. Undertones come
in three types: Warm, Cool, and Neutral. Identifying the undertone is a little more difficult but there are
some techniques to finding it if you're not sure.

Looking at their veins near their wrists. A blue or purple cast to the veins means a cool skin tone while
a green case means a warm skin tone. If you're not sure they are most likely a neutral undertone. You
can also use natural sunlight to look at the shadow of their jawline against a white piece of paper. If the
skin looks yellowish it has a warm tone while a pinkish tone means a cooler undertone.

When this comes to pigment you'll want to either complement, correct and neutralize or compromise
with your colors. For example if you have a client with a cooler skin tone, and you use a cooler toned
ink on them it may heal out with a blueish or purplish cast. This is especially true of colors like black
which can also appear more gray for the same reason. If you are not sure if a color will work well
swatch the skin with a dry q tip and a drop of ink first. For cosmetic procedures it's important to match
the undertone to the ink e.g, a cool toned pigment for cooler toned skin etc. Neutral undertones can
work well with all pigments but you should refer to the Fitzpatrick scale on which may not be suited.

Your judgment call is essential here. Clients obviously will have color preferences but if you want them
to have a good outcome to their tattoo having an educated suggestion will likely give them a better
outcome. E.g a cool toned pink versus a warm toned pink when choosing which to use on their design.

Skin Types
There are seven recognized skin types. While most skin on the body falls only into 2 or 3 of these at
some point you will likely encounter all of them. Skin type can also relate to diseases of the skin and to
medical conditions. Many conditions and medications affect skin type and when in doubt always refer
the client to a doctor or dermatologist to ask about whether their skin is suitable to be tattooed. The
same goes for most medications, we are not trained to give medical advice. When in doubt ask your
client to provide a “Consent of Care” letter from their doctor to provide services. This is especially
important in the case of clients undergoing skin grafts, radiation/cancer care, laser services, or any
medical condition that may seriously affect the integrity of the skin.

It is entirely possible for your client to have more than one skin type across their body. Just because
you have tattooed them previously do not assume. Always inspect the skin first and evaluate the area
you are tattooing both for suitability for the tattoo as well as the best choice of pigment and process.
Type 1 – Oily Skin
Oily skin ages slower than normal skin which is great in some ways but it also affects the healing
process. The excessive sebum production can both dilute the ink and can also mean the process takes
longer which gives the body more time to metabolize the ink as it's healing. This and the texture of the
skin itself can also create a patchy healing. Oily skin often has larger pores which means it is more
prone to breakouts and acne issues. It is essential to clean this oily layer off before starting the tattoo
process and may require both soap and antiseptic wipes to be fully gone. Ironically oily skin is actually
chronically dry.
For a client with oily skin advise them to drink plenty of water 48 hours before the tattoo process and
avoid make-up or other irritants that could cause a break out in the tattoo area. This type of skin
frequently needs touching up and will often heal lighter. It takes shading well but especially fine lining
may be problematic. It is also essential not to overmoisturize during aftercare as this can cause
blemishes and outbreaks. In this case a drier lotion or gel may be better than an ointment for healing.
Oily skin is also more prone to scabbing from the excessive sebum and moisture mix. The pigment may
also become diluted by the oils and blur faster.

Type 2 – Sensitive Skin

Sensitive skin is usually cool undertoned and prone to redness. People with a Fitzpatrick type 1 or 2
(see additional section on Fitzpatrick Scale) often have sensitive skin. Sensitive skin is delicate in
structure and often requires you to keep your machine turned down to avoid damage. As skin ages it
often becomes more sensitive even if it is not a FP 1. People with sensitive skin are more prone to
bleeding as the delicate structure means the capillaries are less protected. Their skin is very vascular
and this also means they are more likely to feel pain during the process.
It's best to go extra gentle on sensitive skin and to go slow to prevent excessive bleeding. For especially
delicate areas on those with thinner skin using a finer needle with a longer taper on a slow setting is
best as it causes less damage. Using excessive force or too large needles on sensitive skin makes it
more likely you will end up breaching the hypodermis and cause blurring or ink creep. The eyelids and
lips always fit into this category because the skin structure is thinner and more delicate.

Type 3 – Normal Skin

Most skin that we tattoo will fall into this category. Any tattoo procedure takes well on this skin and it
will take ink easily. The majority of skin asides from the armpits, neck, palms, soles, lips, eyelids will
fall into this category. There are no special stipulations with normal skin as it should take the tattoo
process easily and without problem as long as the skin is healthy and undamaged (e.g sun burnt).

Type 4 – Acne Prone Skin

Skin that has visible acne or excessive atrophic acne scarring is not suited for tattooing. The texture is
likely to be problematic for healing but the risk of infection is also high. There will likely be a lot of
patchiness and it will push a good portion of the ink out. For skin that has a visible condition like this
it's essential to refer them to a medical practitioner and avoid it for tattooing. This includes even
delicate PMU procedures and scar camouflage should only be done with a consent of care letter. For
atrophic acne scarring no procedures should be performed unless the client has been cleared by a
dermatologist.

Type 5 – Rosacea
Skin that has a ruddy, red undertone is often a sign of rosacea. For years a rosy complexion was
considered a sign of health but if there is an almost sunburned pinkishness to the area it is more likely
to be Rosacea. This type of skin also needs to be referred to a medical practitioner as this is a sign of
inflammation within the skin structure. During the tattoo process the skin becomes inflamed as part of
healing, however if skin is already inflamed it is likely the tattoo won't take well. It can also cause
complications with color as the redness underlying the skin tone will affect the appearance upon
healing. This type of skin is also prone to bleeding as the capillaries are already swollen. Rosacea
sufferers may also have lumpy and pus filled skin which is a huge risk for infection.

Type 6 – Dry Skin

Older skin, Eczema and those prone to dehydration often have dry skin. Dry skin is especially
problematic for healing as the top layers of keratin are usually slower to slough off and will likely be
thicker. This means getting to the correct layer is problematic as the dryness of the skin also makes it
delicate and more apt to tearing. All dry skin is feasible to tattoo as long as it is not due to medical
conditions. Those undergoing chemotherapy often have very dry and delicate skin. In all cases where
the skin is due to medical conditions always ask for either a consent of care or for them to get an ok
from their doctor first.
This type of skin is also difficult for aftercare and may need extra moisturization. It will be prone to
scabbing and flaking which can cause the ink to pull and become patchy. As this type of skin is delicate
use care with the use of dermshield and aftercare products as this could cause tearing of the skin or
irritation and potentially damage both the skin and tattoo. Because dry skin is not well hydrated it is
also not as well supplied with nutrients which can cause a tendency to scar.

Type 7 – Combination Skin

The face, hands and feet are the only areas which may have more than one type of skin at a time. The
thicker skin of the palms and soles is usually similar in type however, while the face may have both
oily and dry areas concurrently. It's especially important when tattooing the face to evaluate what type
of skin you are dealing with before choosing needles and pigment even if you have tattooed the area on
the client previously. This type of skin experiences the most changes due to weather and hormones.
Each section of skin should be treated according to previous skin types. For example, an oily T-zone
should be treated as oily while dry cheeks should be treated as dry. Combination skin is not normally
an issue to tattoo as long as you are conscious of the skin type in the area you are working on.

Skin Diseases and Abnormalities

Just like any organ it is possible for your skin to get “sick”. There are a plethora of diseases of the skin
and unless you plan on becoming a dermatologist it would not be reasonable to know all of them. For
any skin conditions you are unsure of always refer the client to a medical practitioner and ask for a
consent of care. It is possible to still tattoo skin that is not “normal” depending on condition but it is not
advised if you expect good results. There are also some conditions on the skin such as moles that are
perfectly normal but should not be tattooed.

“Normal” Skin Abnormalities

Skin Tags
Skin tags are harmless and usually form where the skin rubs together. They are more often found in
people who are overweight or diabetic. They can be irritated by the tattoo procedure even if you're only
tattooing near them. Skin tags are a type of benign tumor called a fibroma. They are essentially just
excessive skin that has grown on a stalk. They should not be tattooed because the structure is different
from regular skin and because of the fact that they are a form of tumor doing so may initiate them to
become cancerous.

Moles
Moles are generally harmless, if a mole is itching, bleeding or an abnormal shape then there may be
something else going on. This is a type of growth that usually appear within the first 20 years of life
and are fairly common. Some people have more than others and they are often hereditary. A mole may
be black, brown, or pinkish and has a distinct and defined edge. Moles often have a very vascular
structure which means they are prone to bleeding. You should never tattoo over a mole. Disturbing the
structure of a mole can potentially trigger a cancerous response and the structure is also likely to cause
excessive bleeding which will push the ink out.

Freckles/Sun Spots/lentigines
Fitzpatrick types 1 and 2 are especially prone to these marks. They may come and go with sun
exposure but are generally harmless. It is ok to tattoo over these as they do not have any structural
difference in the skin but are simply a patch of excess melanocytes. These are usually found on areas
that get a lot of sun exposure like the cheeks and shoulders.

Others
There are other skin conditions that may not initially affect the tattoo process but may affect how the
pigment ultimately appears. These can be something simple like your client being tan or they can be
medical in nature such as vitiligo or a stain birthmark. Albinism for example is not ideal for tattooing
because the structure is different than normal but with a consent of care is unlikely to cause problems.
Chloasma (hormonal color changes in the skin) also does not change the structure and will disappear
with hormone balance. With conditions that only cause a temporary discoloration it's important to take
this into account when picking color tones as the tone during and after will be very different.

“Abnormal” Skin Abnormalities

Skin Cancer
This is the most dangerous of skin conditions you are likely to encounter. It is not contagious but it has
the potential to be deadly to your client. There are three main types of skin cancer you may encounter.
While you are not a medical professional it is acceptable to refer the client to a medical professional if
you find something concerning in the area of the tattoo. Do not tattoo over something that appears like
this and refer them to a medical professional before tattooing the area. The three main types of skin
counter you may encounter are:
• Basal Cell Carcinoma – This affects mitotically active stem cells in the Stratum Basale of the
epidermis. It is the most superficial of skin cancers and the most common. It is easy to treat,
especially if caught early. While it is not advised to tattoo the area undergoing treatment with a
consent of care other body parts that are unaffected may be safe to tattoo. Use discretion.
 • Squamous Cell Carcinoma – This affects the keratinocytes of the Stratum Spinosum. It is
usually found on the scalp or hands but it can also metastasize and be found elsewhere. It
usually begins by looking like a Basal Cell Carcinoma. Clients will potentially require radiation
or surgery and in these cases you should avoid tattooing them until their doctor gives them the
ok even if the tattoo is not in the area of the issue. It is possible for this to look like a flaky, dry
zit or scab also.

• Malignant Melanoma – This is the deepest and most dangerous of cancers. It is highly
dangerous and potentially deadly. It is caused by uncontrolled growth of melanocytes and
usually develops from a mole. The ABCDE of cancer diagnosis is usually used to determine
melanoma. A mole that is asymmetrical, without a defined border, an abnormal color, and both
large and growing is of concern. Always refer clients to a medical professional if you see
something of concern like this and do not tattoo near the area.

Eczema
Eczema is skin that is dry, flaky, itchy and often scaly. It is not advised to tattoo over active eczema as
the flaking of the epidermis will likely cause patchiness and will also make it hard to implant ink
evenly. Have the client treat their skin before the appointment but be prepared to move the tattoo to an
area of clean skin if possible or abandon the idea if the skin cannot be healed. Eczema skin is extra dry
and will likely need extra aftercare but may still give patchy results. Both pre and post procedure care
are key in tattooing skin with eczema.

Acne
Acne is an inflammatory response from the sebaceous glands. Acne cream can affect the integrity of the
skin (Accutane) and may render it too thin for tattooing as it weakens the skin structure. The cream
itself is also problematic for aftercare. Acne tends to be more prevalent during puberty and you will
encounter it more frequently on younger clients as well as in areas with extra sebaceous glands like the
face. It is possible to get acne anywhere on the body such as the chest and back too. (See previous
section on skin types).

Burned and Sun Damaged Skin

Whether a burn has come from excessive time in the sun, chemicals or a kitchen accident is immaterial.
Burned and damaged skin is unsuited for tattooing as it is actively in the process of healing and results
are uncertain. Burned skin is dehydrated and compromised which means it's already at risk of infection.
It can cause pigments to blur or discolor and will likely push out as the skin sloughs off. Continued sun
exposure after tattooing and subsequent burns may also cause fading and discoloration. Consistent sun
damage may also trigger skin cancer.

Sebohrreic Dermatitis
This is usually found in areas where the skin “folds” and is not necessarily confined to overweight
clients. It can occur in armpits, in the crease on the back of the head, the eyelids, and more and may
also spread if untreated. It is non-contagious but is an itchy and scaly rash with skin that has excessive
flaking. The skin is dry and impossible to get to maintain a tattoo due to texture. Even if you manage to
implant ink successfully it will likely not survive the healing process and will reject.

Psoriasis
This can be triggered by damage to skin that appears healthy. Tattooing is enough damage to trigger
this so proceed with caution and advise the client of the outcome. A consent of care is advised,
especially if they have significant skin that is compromised. Skin that has psoriasis produces cells on
overtime and sheds faster than normal. It will likely push out the ink as it does not have time to settle
during the healing process and may not reach deep enough into the dermis with the additional dead
layers of the stratum corneum.

Scars, stretch marks and Keloids

In theory, all tattoos are scars because the skin is no longer considered “normal” structurally. While
scars are not an active diseases they are still an area of abnormality you are likely to encounter while
tattooing. While all keloids are scars not all scars are keloids. Scars are formed when collagen rich skin
produces too much collagen and does not form the correct connective tissue structure. After the wound
is healed the skin continues to produce collagen, if this becomes excessive and extends outside the
original wound area the scar is called a keloid. Keloids continue to develop even after the wound has
fully healed and will continue to grow if they are damaged. Keloids need medical intervention and
should be directed to a medical diagnosis for treatment. Darker skin is more prone to keloids.
Scars can be both atrophic (sunken) or hypertrophic (raised) but all lack the accessory structures like
sweat glands and hair follicles. Larger scars can be problematic to tattoo because the structure of the
skin is different. With this being the case healing is questionable. For any scar that is still forming and
healing it is not advised to tattoo over it as it will likely be pushed out or absorbed. Depending on the
severity of the scar it is advised to wait 2-5 years until it has finished forming and “settled” before any
tattoo procedure. Some fresh scars may be suited for inkless tattooing but scar camouflage should not
be performed until the scar has settled.
Stretch marks are also a form of scarring. They occur when the dermis layer becomes stretched due to
growth and breaks apart. While the structure is much looser than a knotted scar it is still to be treated
the same. A stretch mark is usually more delicate in structure and may tear with too much or too rough
handling. Tattooing stretch marks is possible and especially with camouflage procedures the skin
should be evaluated properly before tattooing but it is advised that the stretch marks have settled and
achieved a more neutral tone over the fresh purple/pinkish tone they initially have.