Tattoos and medicine may seem an unlikely pairing, but medical tattoos are nothing new. Religious tattoos of ancient Egyptians honored the gods and, possibly, directed divine healing to ailing body parts. Circa 150 CE, Galen, a Greek physician working in the Roman Empire, tattooed pigment onto patients’ corneas to reduce glare and improve their eyesight. In the past century, more and more people have tattooed their medical histories, such as blood type, hereditary conditions, and even medical requests such as “do not resuscitate,” on their wrists and chests. Modern doctors have also used tattoos in reconstructive and cosmetic procedures to disguise scars and restore the appearance of lost body parts, such as nipples for mastectomy patients.

Today, that history comes full circle—as researchers now try to determine if tattooing could be used as a medical tool, giving healthcare providers a better way to administer drugs and vaccines.

It was only recently, in 2018, that scientists figured out exactly what happens in the immune system when you get a tattoo. They identified macrophages, a type of immune cell, as critical players in the process. Macrophages are part of the first responder unit of immune cells, also known as innate immunity. To understand what macrophages do, look no further than the Greek roots of its name: Macro–phage means “large-eater.” These pliable cells, which develop deep in our bone marrow, travel through the bloodstream and target microbial invaders in tissues, engulfing and “eating” them through a process called phagocytosis, thus clearing infections. Often, the response is so fast and effective that we don’t realize we’ve been infected at all.

Macrophages are also the accomplices that make tattoos permanent. When a tattoo needle punctures the skin, it tears apart the skin, fat, and connective tissue in its path. As they’re damaged, these cells release chemical distress signals, which travel into the bloodstream and surrounding tissue. The signals attract immune cells to the damage site and put adjacent cells on high alert. Depending on its size and complexity, a typical tattoo will inflict hundreds of thousands, and possibly millions, of these puncture wounds. Macrophages near the tattoo site, ever on the prowl, ingest any mysterious, foreign substance they happen to find—in this case, targeting the ink the tattoo artist has applied with the tip of their needle. In a twist that researchers still don’t fully understand, the macrophage “eats” the ink but cannot destroy it (one theory is that tattoo inks, which nowadays are usually carbon-based and suspended in a carrier fluid such as distilled water, isopropyl alcohol, or glycerin, are simply resistant to the cell’s enzymatic breakdown strategies).

The macrophage then does one of two things: 1) carry the ink away to a nearby lymph node for disposal or 2) sit there. “Sitting there” is a strategy macrophages sometimes employ with trickier foes. Macrophages and other immune cells will try to engulf as much of the invading material as possible but can’t fully destroy it, so the macrophages hunker down and form a blockade structure with their bodies, called a granuloma, to isolate the pathogen from the uninfected tissues (the macrophage motto: “If you can’t destroy them, trap them.”). When you get a tattoo, some of your macrophages sit and hold the ink to “protect” you, in the process becoming inadvertent guardians, preserving your tattoo design.

Your tattoo design, then, is an artful, exterior display of your body’s immune response.

Tattoo artists have harnessed the body’s defense network to inscribe and preserve art within your skin. It begs the question: Why can’t researchers leverage the same approach to advance medical treatments?

In 2016, the American Academy of Dermatology estimated that one out of every four people in the U.S. is impacted by skin ailments such as microbial infections or various cancers. Another study, in 2019, reported that Americans spend $13.8 billion dollars battling skin and soft tissue infections each year. Physicians today treat serious skin infections by giving patients intravenous or oral medication, which can be costly and can cause side effects. Minor infections may respond to topical ointments and creams, but these don’t always work well because the drugs may have to penetrate the skin barrier to reach the target site, resulting in variable absorption.

Tattooing medications into infected tissues might work better. A fluid dynamics study from 2021 (preliminary version here) used a gelatin block to simulate flesh, and characterized how needles deliver ink to skin. As a needle punctures tissue it creates a brief opening, which draws ink in as the wound closes back. Repetitive needling over the same puncture increases the total volume drawn in. The mechanism yields interesting possibilities for difficult-to-deliver drugs and vaccines.

In a proof-of-concept study using laboratory mice with cutaneous leishmaniasis, a parasitic skin infection marked by inflamed lesions, researchers administered an anti-parasitic drug using three routes: administering it topically as a cream, injecting it into the torso with hypodermic needles (the kind widely used in healthcare) to mimic drug circulation through the bloodstream, and using a commercial tattoo needle to inject medicine directly into the infection site. Tattooing treatment directly into the wound decreased parasite numbers within infected tissues and decreased lesion size and tissue inflammation more effectively than the other techniques. It ensured high drug concentration at the target site, while using less of the drug than other methods. Researchers and pharma companies are also evaluating a similar mechanism, microneedles, for treating skin infections. Microneedle patches for common woes such as acne are already available on the consumer market.

Tattoos may also ease the delivery of vaccinations to prevent disease. Today, most vaccines are administered by hypodermic needles that inject into the muscle. The thicker the vaccine, the larger the needle—and often, the more painful the injection. Human skill impacts pain levels, too. An injection may hurt more if an administrator is inexperienced, and doesn’t know, for instance, how much pressure to apply to the plunger. Tattooing eliminates such problems. Tattoo needles are small compared to traditional hypodermic needles, and are designed to puncture the skin superficially, potentially eliminating the discomfort and pain associated with intramuscular injections. And since puncture frequency is automated by machinery and puncture wounds naturally draw in fluid, tattooing may also reduce human error. One research cohort has designed microneedle patches with needles coated with vaccine to “tattoo” it into the recipient.  Such designs, which can be stuck to the skin like a simple adhesive bandage, can eliminate administration problems created by human error as well as the risk of disease transmission from needle handling and biohazard waste disposal. Solid vaccine patches are also easier to transport and store, as they take up less space than liquid-based vaccines.

It behooves the medical and research community to innovate when existing techniques fail; as a tattooed immunologist myself, it seems to me that developing tattoos for medical applications just makes sense. Tattoos, research, and medicine share a rich history, and the convergence of tattoos and science is a continuation of the human desire to explore and innovate—and beautify and prolong our lives.

If medicine is an art, then art too can be medicine.

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For her Zócalo Sketchbook, Encarnación has created five tattoo designs, each of which gives life to a different animal or plant creation myth: The peacock nods to the tale of Argos, the trusted watchman of Hera who put his eyes on the bird to honor him after his death. The cheetah comes from the traditional Zulu story that explains how the cheetah cried for the first time and got black lines on her face after learning a hunter had killed her cubs. The plants derive from the myth of Narcissus, in which the young hunter gets transformed into his namesake flower after pining after his own image. The catfish pulls from the Japanese tale of Yamazu about a giant fish who lives underground and causes earthquakes and tsunamis. Finally, the spider is inspired by Arachne, the weaver-turned-arachnid, whose fate is a cautionary note for why human shouldn’t try to challenge the gods—or at least not Athena.

“One of the biggest challenges of tattoo design is making a story fit within a small space, while still making it legible and beautiful,” Encarnación tells Zócalo. “That’s where the rich color and overlaid watercolor splatters and textures come in, to breathe life back into the ancient tales and make them exciting for someone who wants to honor them today.”

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But technology is rapidly changing the industry. If any of these people wanted tattoos removed five years ago, it would have meant many painful, expensive treatments—and gambling on the appearance of their skin afterward. Now, laser technology has advanced to where the treatments are more comfortable and safe, and the results are more predictable. As a result, more people with tattoo regret are doing something about it; in the last decade, the tattoo removal industry has grown 440 percent. These advances have brought new demands and costs to those who operate removal technology. And they’ve also opened new doors for people to work in the industry, including me.

Getting into the tattoo removal business wasn’t difficult. I found a job posting on my university’s job site and applied, despite having no previous experience working in medical offices. A week or so later I was at the front desk of a tattoo removal business near downtown Phoenix learning the ropes. Since then, I’ve seen so many bad tattoos that, when people ask, all I can say is “I’ve seen it all.” Those horror stories have helped me manage to withstand peer pressure to get a tattoo, despite the fact that I’m a member of the most inked generation in history, and also from Arizona, which has one of the largest tattoo industries in the country.

The office I work at is one of the few standalone tattoo removal places in the United States, although the numbers are increasing. I’ve only been there for just over a year, but the technology the office works with changes so fast that I’ve been witness to the never-ending scramble to keep up.

Out of all of the methods available to remove or alter a tattoo (including lightening creams, excision, plastic surgery, and microdermabrasion), laser tattoo removal is rapidly becoming the most popular and effective. Why? Think of the tattoo ink sitting in the skin like a boulder. A tattoo removal laser breaks up that boulder into pieces small enough for your body to rid itself of them. The body does this by absorbing the pieces into the blood, then passing them through the liver and out along with other waste. A patient has to get multiple treatments to completely break the tattoo down.

When I’m asked what being hit with the laser feels like, my answer is that it’s like having hot bacon grease splashed on you while being simultaneously snapped with a thick rubber band. (I know because I’ve had sunspots removed with the same laser.) To ease the pain, laser technicians can apply topical numbing, which is usually not very effective. At our office, we have naturopathic doctors (doctors who focus on more “natural” treatments and a holistic view of the body) who are accredited to inject lidocaine, a local anesthetic–like the kind you get at the dentist’s office–to make treatments more bearable. A laser technician certificate alone doesn’t allow people who do tattoo removal to use injectable methods, yet a large portion of people who remove tattoos only have this certificate.

As a new industry, tattoo removal’s standards of care are not well defined, so it’s up to consumers to do their homework. Getting a laser certification usually only takes a few days to a week, so the market is flooded with people who don’t have much experience. As a result, the number of people who aren’t trained well is overwhelming.

The crucial number in tattoo removal is the number of treatments it takes to get rid of a tattoo. For this, every tattoo is different. The color of ink, for instance, plays a big role in determining how many treatments someone needs; black and red are the easiest to remove. One of the biggest factors is the type of laser that’s used. As lasers advance, the number of treatments drops.

Last December, our office purchased the newest laser on the market: the PicoWay. Its parent laser, the PicoSure, debuted what is called “picosecond technology,” which fired laser pulses at a trillionth of a second—or a “picosecond.” This was a huge game changer for tattoo removal, because it broke tattoo ink up into even smaller pieces than what was possible before, making it easier for your body to absorb and process the tattoo. But the PicoSure also had a higher propensity to scar, and couldn’t be used on certain skin types. The PicoWay resolved these problems, making laser tattoo removal possible for a lot more people.

When the new laser finally arrived in March, our office changed profoundly. We cut the estimated amount of treatments in half, which changed the length of the removal process from a year to about six months. In a few cases, patients saw their tattoo clear 50 percent or more just from the first treatment.

But the technological advance also has created new pressures. One of our biggest fears is that the shorter amount of time to remove a tattoo will lead to a shortage of patients. So far, that hasn’t been the case; more people are removing their tattoos than ever before. We’ve done research, and found that many people have wanted to remove tattoos but hadn’t acted because they didn’t know enough about the process, or what they knew was outdated.

Further disruption is coming. Laser manufacturers are already working on the next step, a “femtosecond” tattoo-removal laser that would split pulses even shorter—only one quadrillionth of a second between zaps.

In the near future, tattoos might in fact come off as easily as they go on. Even when it comes to permanence, change is accelerating.

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Since its founding in 1897, Long Beach has long been a sanctuary city for dreamers and cast-offs: young Iowans seeking warmth; oilmen drilling for wealth; navy sailors heading out for adventures; blacks escaping Southern racism; gays and lesbians building a safe haven; and refugees fleeing war in Latin America and Southeast Asia.

Unlike other Los Angeles cities that consume their history in an ouroboros-like cycle of drywall redevelopment and garish Mediterranean villas, Long Beach doesn’t just remember its past—it survives because of it.

We remember through traditional means, like our 50-year old Long Beach Historical Society and the iconic Acres of Books, once the largest used bookstore in California. We also remember through our architecture (the downtown Pike rollercoaster bridge), our murals (dozens bombed across town), and of course, our music (Snoop Dogg and Sublime).

However, we also remember in a more corporeal way. The walls of the Long Beach Clothing Company store in the Bixby Knolls neighborhood are lined with hundreds of photographs of people tattooed with “Long Beach” or “LB” on their bodies. I particularly love the ones of local iron tattooed onto local flesh: the underappreciated Vincent Thomas Bridge spanning a man’s chest and the British ocean liner Queen Mary moored to a torso.

Civic pride tattoos are not rare, but in Long Beach, like most everything else here, they have a rich past. A few blocks away from the bustling Aquarium of the Pacific and surrounded by modern apartment buildings is a small corner shop located at 22 Chestnut Place: Outer Limits Tattoo. Before that, it was Bert Grimm’s World Famous Tattoo where, since 1927, thousands of sailors from the now-shuttered Long Beach Naval Shipyard were tattooed. Black-and-white photographs of tattooed sailors, restored original artwork, and a backroom museum of tattoo guns and needles make it obvious that renowned tattoo artist and current owner Kari Barba deeply respects the locale’s history. Together, the shops are the longest-running tattoo parlor in the United States.

“Tattoos are proof of our existence,” said Shay Bredimus, a gallery-represented visual artist and painter who also has tattooed at Outer Limits for six years. As we spoke, he worked on a gothic tattoo of the skull-like hill Golgotha, the site of Christ’s crucifixion, on a man’s inner arm. “In the modern age, they are one of our last rites of passage, an agreed-upon blood ritual.”

Unknown to most, Long Beach sits atop the United States’ third largest domestic oil field. And it is sinking. Every day, thousands of gallons of oil are pumped from beneath the city. To replace those gaps in the ground, engineers pump water back into the ground, preventing the city from collapsing onto itself.

My city hasn’t always been so lucky. More often, it has collapsed, sometimes to be rebuilt again, sometimes not. During the riots in 1992, army trucks rumbled down the streets and my neighborhood burned. In the “hot summer” of 1998, 11 were killed in a vicious interracial gang war. But sometimes the change is good and peaceable. In 2014, the city elected its first Latino and openly gay mayor.

Amidst so much turmoil and impermanence, I understand that we have to store our memories on the most intimate of place of all: our bodies. We remember with our tattoos, our history inked permanently into our skin. As my tattoo artist Aleks Figueroa of Dream Jungle Tattoo said, “Tattoos make the world less impermanent.”

A few hours after my visit to Outer Limits, as I wandered around Signal Hill, which has one of the best views in Southern California, I crossed paths with three Cambodian-American young men. They had a mix of street art and Khmer iconography tattooed on their arms, stomachs, backs, necks, and even their heads. I could not take my eyes off them. One had an image of a stone Buddha head etched into his neck. Another’s entire left arm was a tribute to Kobe Bryant.

I introduced myself with the universal city greeting, an upward head nod. The leader of the group, it turned out, was Chanthy Sok, a.k.a. CS, a local rapper who is leading a Long Beach rap renaissance called the Cambo Movement. He invited me to his North Hollywood recording studio and then later said this about his tattoos, the temples of Angkor Wat and “Made in Cambodia” inked across his stomach.

“Growing up in Long Beach, we used to be despised for being Cambodian. I used to ask myself, ‘Why can’t I be something else?’” he told me. But while serving almost 10 years in prison, “I studied up about my people. We weren’t just the victims of genocide and the Killing Fields. We weren’t barbarians and jungle people. It took a strong civilization to build Angkor Wat. My tattoo is about redemption. After all those years of hating myself, I owed it to myself.”

CS’s new tattoo also covers up a tattoo of his old gang affiliation; it’s both facade and symbol of rebirth.

My family moved to North Long Beach in 1979. We were refugees from the Vietnam War. In addition to the traditional trials and tribulations of having immigrant-refugee parents (poverty, cultural differences, language difficulties), my family faced additional trying circumstances. For most of my life, both my parents had been disabled by strokes, my dad when I was just a teen and my mom in 2005, a month before I turned 30. In some way or another, I had been responsible for their care for almost three decades. My mom passed away in 2009 and my dad followed four years later. They are both buried in Long Beach, a few blocks from where we replanted our roots.

My two tattoos memorialize both of them. My mom’s signature is inked onto the inside of my left forearm in a graceful calligraphy that resembles Arabic writing. It’s to honor my life as a writer and all the times my mom read to me—in English—after an exhausting day of work. My dad’s paratrooper wings from his service in the South Vietnamese military adorn my right inner forearm. His body was broken for so many years that I wanted to remember him young and strong, jumping ably from helicopters and airplanes.

When we fled Vietnam, my mom was already six months pregnant, physically lugging me across time zones and borders. In his new American life my dad, a former schoolteacher, sold furniture and worked at a construction company. My mom toiled as an office clerk and manicurist. It was not glamorous work, but they did what they had to provide food and shelter. As they carried me, I now carry them.

My tattoos also link my parents to their kin. When my first son was born, I brought him into the world with my mom’s name there by his side. In a few weeks my second son will be born, and I will welcome him into the world with arms bearing both his grandparents’ memories. When I teach my sons how to shoot a basketball or read a book to them, they will see those same tattoos and ask them about them. Then I will tell them about their grandparents.

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