10.18 Traumatic Tattoos and Abrasions

agk’s Library of Common Simple Emergencies

Presentation

The patient will usually have fallen onto a coarse surface such as a blacktop or macadam road. Most frequently, the skin of the face, forehead, chin, hands and knees are abraded. When pigmented foreign particles are impregnated within the dermis adventita, tattooing will occur. An explosive form of tattooing can also be seen with the use of firecrackers, firearms, and homemade bombs.

What to do:

• Cleanse the wound with nondestructive agents (e.g., normal saline, SurClens, 1% povidone-iodine in normal saline) and provide tetanus prophylaxis.
• With explosive tattooing, particles are generally deeply embedded and will require plastic surgical consultation. Any particles embedded in the dermis may become permanent tattoos. Abrasions that are both large (more than several square centimeters) and uniformly deep into the dermis or below (so that no skin appendages, such as hair follicles, to provide a reservoir of regenerating basal epithelium remain), may also require consultation and/or skin grafts.
• With abrasions and abrasive tattooing, the area can usually be adequately anesthetised by applying lidocaine jelly, viscous lidocaine or gauze soaked with a mixture of lidocaine, tetracaine and epinephrine directly onto the wound for approximately 5 minutes. If this is not successful, locally infiltrate with 1% buffered lidocaine using a 25-gauge 3" needle for large areas.
• The wound should now be cleaned with a surgical scrub brush, saline and surgical soap. When impregnated material remains, use a sterile stiff toothbrush to clean the wound or use the side of a #10 scalpel blade to scrape away any debris. While working, continuously cleanse the wound surface with gauze soaked in normal saline to reveal any additional foreign particles. Large granules may be removed with the tip of a #11 blade.
• Wounds should be left open with antibiotic ointment applied. The patient should be instructed to gently wash the area 3-4 times per day and continue applying the ointment until the wound becomes dry and comfortable under a new coat of epithelium, which may require a few weeks.
• An alternative to the above when the wound has been adequately cleansed, is to use the same antibiotic ointment with a closed dressing of Adaptic gauze and a scheduled dressing change within 2-3 days.
• Provide wound care instructions that include danger signs of infection.

What not to do:

• Do not ignore embedded particles. If they cannot be completely removed, inform the patient about the probability of permanent tattooing and arrange a plastic surgical consultation.

Discussion:

The technique of tattooing involves painting pigment on the skin, and then injecting it through the epidermis into the dermis with a needle. As the epidermis heals, the pigment particles are ingested by macrophages and permanently bound into the dermis. Immediate care of traumatic tattoos is important because once the particles are embedded and healing is complete, it becomes difficult to remove them without scarring. It is advisable for a patient to protect a dermabraded area from sunlight for approximately 1 year to minimize excessive melanin pigmentation of the site.

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