Is it safe for individuals with psoriasis or eczema to get a tattoo, considering the possibility of the Koebner phenomenon?
When considering getting a tattoo, an individual’s skin health must be considered. If an individual has a primary dermatologic condition (PDC), when the skin is traumatized—such as by receiving a tattoo—the individual can exhibit a Koebner phenomenon. Infection Control Today® (ICT®) examines what a Koebner phenomenon is, how having a PDC can affect the patient getting the tattoo, and whether it depends on where the tattoo is located.
The Koebner phenomenon (KP) was discussed in a recent study. Heinrich Koebner first described the KP in 1876, and it “is the appearance of new skin lesions on previously unaffected skin secondary to trauma. This phenomenon is also termed the isomorphic (from Greek, “equal shape”) response, given the fact that the new lesions that appear are clinically and histologically identical to the patient’s underlying cutaneous disease.”1
The study’s investigators explain further: “A patient with psoriasis who exhibits koebnerization (and is said to be “Koebner-positive”) will develop new psoriasiform lesions along sites of skin injury, even if trivial. Koebner phenomenon can develop in any anatomic site, including in classic areas of psoriatic involvement and in regions that are usually spared, such as the face. The phenomenon shows dynamic behavior. Patients may be “Koebner-negative” at one point in life but may later become “Koebner-positive.”1
In an exclusive interview, Bernard Cohen, MD, told ICT® about the Koebner phenomenon. Cohen has over 40 years of experience as a pediatric dermatologist, holding positions as professor of pediatrics and dermatology at Johns Hopkins University School of Medicine and currently as director of the Advocacy Committee for the American Academy of Pediatrics Section on Pediatric Dermatology.
“If [an individual] has a primary dermatologic condition (PDD), let’s say you have psoriasis. When you traumatize the skin, you can get a KP. That is, your skin rash of psoriasis can become reactivated in the area where you traumatize the skin. [For example,] you have a history of psoriasis and get a tattoo on your arm, back, or leg. There is some risk that trauma to the skin can cause reactivation. If your psoriasis is in remission, it can cause it to pop up again and flare.
“There would be 2 issues there. One would be that you can make your skin rash flare. And the second thing would be that when your skin rash flares, there's some increased risk of secondary infection. That's much more common.”
Cohen says that although psoriasis is not unusual, eczema is much more common. Both can cause the KP. Again, if you do something that irritates the skin, it can cause a flare of your eczema. If you scratch, there is some increased risk of a secondary infection as well.” Cohen said that for older children and adults, eczema is more common on arms, legs, and the flexural creases. But he warns that “it certainly can pop up in other areas.”
Cohen said that if an individual wants to get a tattoo, do it in a place where they tend not to get psoriasis. He cautions that flare-ups can still happen. “I'm not saying that it couldn't flare when an arm or leg or someplace else where [the individual] doesn't get psoriasis. But it's probably better to put it in an area where your psoriasis tends not to flare. So I would be very cautious about that.”
“One of the things that [dermatologists] often recommend is that you use a clean skin ointment to protect the area to keep it moist a little bit. Using a little Vaseline or Aquaphor, or something like that, and maybe if you put it under a little Vaseline gauze if you have a tattoo or [flare-up] place, keeping it moist may facilitate healing more quickly.” Cohen specified that using any ointment with alcohol in it is not recommended. He recommends Vaseline Aquaphor and other topical moisturizers because they “can be very protective, and they facilitate healing.”
Overall, he told ICT® that if you want to lessen your chances of getting a KP, “if you have a [PDD], you want to make sure that number 1, it's under good control. It's in remission. Number 2, you're prepared to treat [if psoriasis or other primary dermatologic condition] if it flares up when you traumatize the skin, and again, a tattoo would be a way that you could traumatize the skin and trigger that response.”
However, psoriasis and eczema are not the only primary dermatologic disorder to be concerned about. “If somebody has a history of shingles (herpes zoster), trauma to the skin can cause reactivation. Let's say you're putting a tattoo gun on your arm, and you've had shingles on your arm, or you've had it on your trunk, and you get a tattoo on one of those areas of your skin where you'd want to avoid trauma, and I consider a tattoo to be somewhat traumatic because there is a risk of reactivation of shingles,” you can have an outbreak.
Another PDD is herpes simplex. “I can't even imagine the reactivation of herpes, herpes simplex,” Cohen said. “If you had a herpes rash, not necessarily shingles, but herpes somewhere, like if you're getting a tattoo on your forehead, cheek, or lips, which is one of the more common sites for herpes, and then if you traumatize the area, that can be something that gets reactivated too. It is important to recognize [that] it hurts.”
Herpes simplex, Cohen explained, doesn't look very different from herpes zoster (shingles). “Because herpes zoster tends to occur along a skin nerve, you'll see clusters of little blisters, maybe 2 or 3 millimeters in diameter. You'll see clusters of them, but there'll be a line. Whereas with herpes simplex, they will be scattered. If you reactivate it, it's going to be scattered everywhere. If you scratch it and then inoculate around on the skin, you can get little spots in all the places where you get clusters,” Cohen said. “There are some oral antivirals that can take it away quickly. It's something that, if you see it, it's something you want to show your physician and get an oral antiviral quickly to get rid of it.”
1. Sanchez DP, Sonthalia S. Koebner phenomenon. In: StatPearls. StatPearls Publishing; 2022. Accessed February 15, 2023. http://www.ncbi.nlm.nih.gov/books/NBK553108/