Why is it recommended to avoid inserting peripheral guided intravenous (IV) lines in skin with tattoos?

Avoiding Peripheral IV Insertion Through Tattooed Skin

Peripheral IV lines should not be inserted through tattooed skin due to unknown effects on insulin absorption, potential for infection activation, and presence of toxic compounds in tattoo ink that may enter the bloodstream.

Rationale for Avoiding Tattoos for IV Access

Unknown Effects on Medication Absorption

• According to the most recent guidelines from the Mayo Clinic (2025), healthcare providers should "avoid injecting into scars, stretch marks, or tattoos as their impact on administering correctly to the subcutaneous layer or altering absorption rates is unknown" 1
• While this guideline specifically addresses insulin injections, the same principle applies to IV medications, as the tattoo ink particles in the dermis could potentially interfere with medication delivery and absorption

Risk of Infection

• Tattoo ink contains foreign particles that remain permanently in the dermis
• Inserting an IV through tattooed skin may:
  • Disrupt the tattoo pigment particles
  • Potentially introduce these particles directly into the bloodstream
  • Activate dormant infections present in the tattooed area

Toxic Compounds in Tattoo Ink

• Tattoo inks contain numerous potentially harmful substances including 2:
  • Polycyclic aromatic hydrocarbons (PAHs)
  • Heavy metals (cadmium, lead, mercury)
  • Primary aromatic amines (PAAs)
• These compounds are either present in the ink or produced inside the skin through various processes
• Some of these compounds are classified as carcinogenic to humans (Group 1) or possibly carcinogenic (Group 2B)
• IV insertion through tattooed skin could potentially introduce these compounds directly into the bloodstream

Risk of Viral Activation

• Tattooed skin has been associated with viral activation, including herpes simplex virus 3, 4
• Needle trauma from IV insertion could potentially trigger reactivation of dormant viruses in the tattooed area

Best Practices for IV Access

Site Selection Guidelines

• The Association of Anaesthetists of Great Britain and Ireland (2016) recommends using transillumination, ultrasound, and infrared devices when peripheral access is difficult 1
• Choose non-tattooed areas for IV access when possible
• If a patient has extensive tattoos, consider:
  • Areas between tattoos
  • Distal extremities that may be tattoo-free
  • The dorsum of the hand (if free of tattoos)

Alternative Access Options

When tattooed skin cannot be avoided:

1. Ultrasound-guided peripheral IV in non-tattooed areas 1
2. Midline catheters (10-20 cm) inserted with ultrasound guidance for short to medium-term access 1, 5
3. Intraosseous access in emergency situations when IV access is difficult 1, 5
4. Central venous catheters when peripheral access is inappropriate or impossible 5

Documentation and Communication

• Clearly document in the patient's chart that IV insertion was avoided in tattooed areas
• Communicate the rationale to patients who may question site selection
• Educate staff about the importance of avoiding tattooed skin for IV access

By avoiding IV insertion through tattooed skin, healthcare providers can minimize potential risks to patients while ensuring effective medication delivery and reducing complications.