Tattoo Regret, Complications, and Removal: A Cross-Sectional Study among Tattooed Individuals in Saudi Arabia

Background A tattoo is a pigment permanently deposited into the skin to create different patterns. The worldwide percentage of tattooed individuals, as well as the level of tattoo regret, complications, and removal, has increased. However, data from Saudi Arabia are lacking. Objective To determine the rates of tattoo regret, complications, and removal among tattooed individuals in Saudi Arabia. Methods A cross-sectional study using an online survey was conducted in Riyadh, Saudi Arabia. A link to the survey was distributed through social media and contained twenty questions about participants' demographics, tattoo practices, regret, removal, and complications. Data were analyzed using the Statistical Package for Social Sciences (SPSS). A P value <0.05 was considered statistically significant. Results A total of 181 tattooed individuals participated in the study. Most of them were females (95.6%), and 76.7% had their first tattoo at an age over eighteen years. A total of 47.5% had one tattoo session, and the most common body site was the eyebrows (57.5%). Fifty-eight percent regretted their tattoo, and 42.5% attempted to remove it. Upper extremity tattoos were significantly associated with regret (72.3%) (P=0.004) and removal (56.9%) (P=0.003). Tattoo removal was mostly due to cultural reasons (74%). Local itching (32%), pain (22.7%), and infection (10.5%) were reported and associated with tattoo regret (P < 0.05). Itching was significant in 65.4% of head and neck tattoos and 41.5% of upper extremity tattoos (P < 0.05). Participants were aware that laser is the best method for tattoo removal. Conclusion Among tattooed individuals in Saudi Arabia, the rate of tattoo regret and removal is high, and the most reported complication is pruritus.


Introduction
Tattooing is the practice of depositing pigment into the dermal layer of the skin [1].In the last several decades, the rate of tattooing has increased worldwide, particularly among young individuals [2][3][4].Tere are diferent types of tattoo practices, including professional tattoos and cosmetic tattoos, such as eyebrows, eyeliner, and lip tattoos [5].As tattoos have become more common, the rate of tattoo regret has subsequently risen [4].An American study published in 2016 showed that 23% of tattooed individuals regret getting tattooed, in comparison to 14% in 2012 [6].
Several tattoo complications have been reported in the literature, including local and systemic infections, granulomatous reactions, scarring, photodermatitis, pseudolymphoma, and hypersensitivity reactions [7,8].Some patients with tattoo complications have reported a decreased quality of life [9].
As the practice of tattooing continues to grow in popularity, the desire for tattoo removal also grows [10,11].Multiple factors contribute to the rate of tattoo regret and the decision to have tattoos removed, including changes in lifestyle, occupation, or partner; tattoo color or shape; and tattoos received at an early age [12,13].Diferent modalities of tattoo removal have been studied with variable outcomes [5].Te most common and efective technique for tattoo removal is the quality-switched (QS) laser.It has demonstrated diverse outcomes depending on the parameters and techniques that have been used as well as the type of tattoo [10].Te most common lasers used for tattoo removal are neodymium-doped yttrium aluminum garnet (Nd-YAG) lasers at wavelengths of 532 nm and 1,064 nm, the QS 755 nm alexandrite laser, and the QS 694 nm Ruby laser [14].Recently, picosecond lasers have become more favorable for tattoo removal [15].
To our knowledge, no study has investigated the rate of tattoo regret, complications, and removal among the Saudi population.Tis study aimed to determine the rates of tattoo regret, complications, and removal among tattooed individuals in Saudi Arabia.

Methodology
A cross-sectional study using an online survey was conducted.Te survey items were based on those of previous similar studies, with modifcations [4,12].Te survey was translated into Arabic by a bilingual health science researcher and tested by two other bilingual health science researchers.A pilot study was conducted on ffteen randomly chosen participants to determine its comprehensibility, the time required to complete the survey, and any technical problems.Te results of the pilot study are not included here.Te study was conducted in Riyadh, Saudi Arabia.After obtaining the necessary approval from the Institutional Review Board of King Saud University, a link to the survey was distributed through diferent social media networks (Twitter, Snapchat, and Instagram) during the period from November 2022 to March 2023.
Te fnal survey was composed of four sections.Te frst section included questions about basic demographics, age, gender, and nationality, and basic tattoo information, including the number of tattoo sessions, body sites of tattoos, and age at frst tattoo.Te second section contained questions to evaluate tattoo regret, including whether the participant regrets any of his or her current tattoos, their desire for tattoo removal at no charge, and their willingness to get a new tattoo.Te third section included questions about tattoo complications, including itchiness, pain, infections, and other complications.Participants were requested to report tattoos that were pruritic or painful for more than 1 month after tattoo placement, as tattoos usually take 2-3 weeks to heal completely [12,16].Te last section involved questions about tattoo removal, including attempts at removing any tattoo, removal sites, removal causes, to whom they would go for a tattoo removal, the most efective method of removing tattoos, and if they think the current methods can completely remove tattoos.
Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 24.Frequency distributions were used for the numbers and percentages of qualitative variables.Te chi-square test was used to compare the regret rate with other characteristics.Fisher's exact test was used instead of a two-by-two table that has a small sample size and where more than 20% of cells have expected counts less than 5.A P value <0.05 was considered statistically signifcant.

Results
A total of 181 tattooed individuals were included in the study, most of whom were females (95.6%) and Saudis (96.7%).More than two-thirds of the participants were aged between 18 and 35 years, and almost half of them (48.6%) got their frst tattoo between the ages of 18 and 25 years.A total of 47.5% of tattooed individuals had only one tattoo session, 29.3% had two sessions, and 23.2% had three or more sessions.Te most common sites of tattoos among the participants were the eyebrows (57.5%); upper extremities (34.9%), which included the hands, forearms, and arms, and the lower extremities (16.1%), which included the feet, legs, and thighs (Table 1).
More than half of the participants regretted their current tattoos (58%), would like to have one or more tattoos removed (66.3%), and were not considering getting a new tattoo within the next few years (62.4%).Of the participants who regretted their tattoos, 48.6% were aged between 18 and 25 years, 33.3% were aged between 26 and 35 years, 15.2% were aged between 36 and 45 years, and 2.9% were 46 years or older (P � 0.241).Furthermore, 53.3% of participants who regretted their tattoos had their frst tattoo between the ages of 18 and 25 years, 22.9% were between the ages of 26 and 35 years, and 13.3% were younger than 18 years (P � 0.132).
Various tattoo complications were reported by the participants, including skin itching (32%), local pain during or after receiving a tattoo (22.7%), cutaneous infection (10.5%), and other complications (3.6%), such as skin erythema, small pimples, peeling, and changes in tattoo color (Figure 1).No systemic complications were reported.Most tattoo complications were signifcantly associated with tattoo regret.A total of 43.8% of participants who experienced itching and 31.4% who experienced pain during or after the process regretted their tattoos.In addition, 15.2% of individuals who experienced an infection regretted their tattoos (P � 0.014) (Table 2).
A total of 42.5% of participants attempted to remove one of their tattoos.Te most common sites for tattoo removal were the eyebrows (49.4%), upper extremities (35%), and lower extremities (16.9%).Te most common reasons for tattoo removal were cultural causes (74%), poor tattoo art (35%), and tattoos received at a young age (33.8%).Ninetytwo percent of tattooed individuals chose a dermatology clinic as the appropriate place for tattoo removal, while 6% chose to visit a tattoo artist.A total of 93.9% of subjects believed that laser treatment was the most efective method for tattoo removal.In addition, 44.8% of respondents believed that the current medical methods available could completely remove tattoos with no traces or remnant pigmentation, while 37.6% did not.On the other hand, 17.7% of participants believed that current medical methods could remove tattoos completely before receiving their tattoos; however, their beliefs changed after receiving their tattoos (Table 3).
Te association between tattoo location and regret, removal, and complications was investigated.For tattoos on the upper extremities, 72.3% of participants reported regret and 56.9% of participants reported removal (P < 0.05) (Table 4).Head and neck tattoos and upper extremity tattoos were signifcantly associated with itching in 65.4% and 41.5% of participants, respectively (P < 0.05).Individuals with 2 Dermatology Research and Practice tattoos on the eyebrows, neck and shoulders, and lower extremities also reported regret and tattoo removal (P > 0.05).Itching was also reported in tattoos on the lower extremities and head and neck (P > 0.05); other complications, including pain and skin infection, were also reported in tattoos placed at diferent body sites (P > 0.05).

Discussion
Te present study has highlighted many important points regarding current tattoo practices and their consequences in Saudi Arabia.Traditionally, tattooing in Western countries was more prevalent among males; however, tattoo rates among females have increased in the last two decades, reaching a similar percentage in both genders [2,3,17].Cosmetic tattooing has contributed to the increase in female tattoo rates [18,19].In our study, most participants were females, and the eyebrows were the most favored site for tattooing.Tis is consistent with the observed increase in eyebrow tattoos during and after the era of COVID-19 along with the mandatory wearing of face masks [20].Tis can be explained by the fact that eyebrow makeup is timeconsuming, and females are choosing to wear more permanent makeup using tattoos.Furthermore, we observed  Dermatology Research and Practice that most tattooed individuals received their frst tattoo after the age of 18 years, which is consistent with previous studies that reported that small percentages of tattooed individuals received their frst tattoo while they were of school age [12].Te literature demonstrates variable results concerning tattoo regret worldwide.An American study showed that 23% of adults with tattoos regret having a tattoo [12], and a study conducted in Turkey showed that 21.7% of participants wanted to remove their tattoos due to regret [21].In other previous studies, it has been reported that 16-44% of people with tattoos regret at least one of them [22,23].A higher rate of tattoo regret was observed in our study.We investigated the factors that contributed to regret in tattooed individuals in Saudi Arabia.Patients who got their tattoos at  an early age demonstrated more regret than those who were tattooed later in life, which is consistent with multiple previous studies [12,21].Te eyebrows and upper extremities were the most commonly reported sites of tattoo removal in our study, with the latter being signifcantly related to regret and removal rates.Similarly, publications have shown that the most commonly reported sites of tattoo regret are the face and upper extremities [21].Tis can be explained by the fact that the face and upper extremities are exposed more frequently than the lower extremities and trunk.A wide spectrum of tattoo complications has been reported in the literature, ranging from mild erythema and pruritus to cutaneous malignancies [7,13,24,25].Pruritus, pain, and cutaneous infections were reported and signifcantly associated with tattoo regret in our study.Our fnding supports the notion that tattoo complications play a role in tattoo regret [13].Moreover, we reported a higher percentage of tattoo removal attempts than a study published in 2015 among 501 Americans, which reported that only 7% of participants attempted to remove one of their tattoos [12].In the authors' opinion, the high rate of tattoo removal can be explained, to some extent, by the free access of Saudi citizens to health care facilities and the availability of tattoo removal lasers in most of the secondary and tertiary hospitals in Saudi Arabia.Cultural unacceptance and poor tattoo art were the top causes of tattoo removal in our study.However, in previous studies, not liking the tattoo anymore and the need to be eligible for an armed forces job were the most commonly reported reasons for tattoo removal [21,26].Tis diference is possibly due to the cultural variety among diferent study locations, and it suggests that the cultural unacceptance of tattoos plays a role in tattoo regret and removal.
To date, no treatment method has been identifed to obliterate tattoos with no residues or adverse efects [14].However, QS lasers are considered to be the most efective method of tattoo removal [14].Participants who chose to remove their tattoos were aware that the most efective method for tattoo removal is laser therapy and that it should be performed by a dermatologist rather than a nonmedical professional such as a tattoo artist.To our knowledge, no study has tested the awareness of patients with tattoos regarding available removal methods.We found that only one-third of participants knew that the currently available methods might be unable to remove a tattoo completely with no residue or pigmentation.Tis lack of knowledge before getting a tattoo might have contributed to regret when removal attempts did not meet expectations.
In conclusion, this is the frst study to report the rate of tattoo regret, complications, and removal among the Saudi population.Most tattooed individuals in Saudi Arabia have regretted their tattoos.Te factors related to tattoo regret include placing a tattoo at an age younger than 25 years, developing cutaneous complications at the tattoo site such as pruritus and pain, and placing the tattoo at an exposed body site such as the face and upper extremities.We further report a high percentage of tattoo removal attempts where half of the individuals with eyebrow tattoos have attempted to remove them.Our fndings demonstrated higher rates of tattoo regret and removal than previously reported worldwide.
A few limitations of the present study should be considered.First, although using an online survey helps to reach a larger number of the targeted sample than distributing paper surveys, people who do not have access to the Internet or do not prefer online surveys can be missed.Also, being self-administered takes a shorter time to collect the data than in-person interviews, yet reporting bias cannot be avoided.Second, the cross-sectional design of the study limits the clinical confrmation of tattoo complications, particularly infections, as well as identifying the causes of tattoo regret and removal.Lastly, the number of male participants and females older than 36 years included in the study was low.Tese gender and age biases are possibly due to the small sample size.Te predominance of female participants while lacking the previous data on the male-to-female ratio of tattooed individuals in Saudi Arabia might afect the generalizability of the results.
We recommend longitudinal studies with larger sample sizes to include more males and females in all age categories using both online surveys and in-person interviews to overcome these limitations.Analysis of gender variations and cross-cultural comparisons are also recommended in future studies.

Figure 1 :
Figure 1: Rates of tattoo complications among 181 tattooed individuals in Saudi Arabia.

Table 1 :
Demographics and basic tattoo information of 181 tattooed individuals in Saudi Arabia.
*One or more sites were selected per participant.

Table 3 :
Tattoo removal rate, causes, and practices among 181 tattooed individuals in Saudi Arabia.
* One or more choices were selected per participant.

Table 2 :
Te relation between the rate of tattoo regret and tattoo complications among 181 tattooed individuals in Saudi Arabia.

Table 4 :
Rate of tattoo regret and tattoo removal according to tattoo site among 181 tattooed individuals in Saudi Arabia.