Interferential current caused burn over tattoo

I have used IFT for nearly 40 years and never come across this. Many patients these days have tattoos and I have never had a problem. I even treated my daughter in law when she was having laser treatment to remove a tattoo and IFT increased the healing rate and decreased the pain for her. I have seen patients with burns from IFT (also medico-legal Expert cases) and we have had a few in the practice. They were caused by new physios and students not ensuring good contact or patients turning up the intensity to see how high they could get it even after being instructed as to the right low level sensation. It is interesting to note that I have only ever seen one woman with a burn. I think I would strongly dispute the ink theory based purely on clinical experience of somewhere in the order of 150,000 treatments carried out with IFT. In my experience, it is down to poor contact of the electrodes; intensity too high, or some insulating material on the skin eg some skin creams, or as in one medico-legal case where the physio had put the foot in a wax bath first and not removed all the wax before applying the IFT. Was it only one electrode that caused the burn? Were there others over the tattoo? Some years ago now, I was involved in investigating the incidence and type of burns. Notably, they all were the same size and nature - a small circular blister - regardless of the size of the electrode. At that time, we wondered if the problem was putting the electrode over an acupuncture point, which are points of lowered skin resistance, but given the number of acupuncture points on the body, you would expect there to be a much higher incidence of burns. I would put my money on poor contact of the electrode.

Apologies for joining the discussion so late. I hope that Terry Redmond is still accessing the site. I agree with Richard Liebano that the culprit is likely too high current density; i.e. this is not a chemical burn because there is zero net charge on the skin using IFC; but possibly increased current flow within the pigmented compared with the non-pigmented area of skin. It is very interesting to know that we should consider the effect of ink ions in the skin. Both the authors cited by Richard Liebano used very small self-adhesive electrodes (Satter possibly combined with ice; heaven help us) which suggests current density as the cause of those burns. Terry: I hope you will write this up as a case history & submit for publication.

My guess is the presence of metallic compounds found in tattoo pigments that could change the skin impedance on these areas, increasing the current density. There are a few reports of skin burning with the use of IFC but not due to tattoos. I hope this helps.

1. Third-degree burns incurred as a result of interferential current therapy. Satter EK. Am J Dermatopathol. 2008 Jun;30(3):281-3. doi: 10.1097/DAD.0b013e31816a9d4f. PMID: 18496434

2. Full-thickness burn formation after the use of electrical stimulation for rehabilitation of unicompartmental knee arthroplasty. Ford KS, Shrader MW, Smith J, McLean TJ, Dahm DL. J Arthroplasty. 2005 Oct;20(7):950-3. PMID: 16230253

Did you use self-adhesive electrodes???

Prof Tim Watson said:

thinking about this one again last night. I know that there have been some studies on the effect of tattoos (and skin colour) on laser penetration, but not seen anything on e stim. Does anybody fancy having a look at it - just a pilot to start with - say e stim on a volunteer with tatoos and compare current needed for effect X (say sensory onset) in comparable skin areas with and without skin inking - so if they had a tattoo on extensor forearm one side and not the other - for example - it might make an interesting preliminary????? just a thought

We might look into it - time and resource permitting (and a volunteer)

terry_redmond260 said:

luisef258 said:

Strange. Just for precaution you should check on the equipment.

Equipment was the first thing I checked, No shorts, recently replaced electrodes, Bioengineering technicians tests and certifies equipment every August, last time was checked was just one month ago. As clinic manager I also thought it was strange, so after checking the equipment I started to research the contents of Tattoo ink, it was surprising the conductive mediums in this ink, including carbon, Iron Oxide, arsenic, lead, and nickel. At my clinic we are now cautioning clients if they have tattoo's in the area of treatment.

I'll just add, that without knowing what the technicians test for and what parameters. I would not entirely rule out equipment. Depending on many output & regulation design factors, an unusual load from the tattoo factor could cause abnormal output. When we are testing new output designs we often see unusual parameters that could cause issue, that are addressed. Our products being primarily consumer based are designed with much greater safety margin on output controls than that of a professional use device.

thinking about this one again last night. I know that there have been some studies on the effect of tattoos (and skin colour) on laser penetration, but not seen anything on e stim. Does anybody fancy having a look at it - just a pilot to start with - say e stim on a volunteer with tatoos and compare current needed for effect X (say sensory onset) in comparable skin areas with and without skin inking - so if they had a tattoo on extensor forearm one side and not the other - for example - it might make an interesting preliminary????? just a thought

Not heard for such response to EStim as such . Only reason - I may think ....if it does REALLY relates to TATTO - that if type of color INK used increases the impedence of skin to substantial levels - thus resulting in increase in Potential difference to deliver desired amount of current output levels - may case burn.... If the device is NOT protected by high level of PD generation.... That's my wildest guess...!

Terry. Thanks for raising this one. As others have mentioned, a lot of the contraindication literature is based on a combination of 'expert opinion' and what is published. Most therapists (unlike medics for example) seem reluctant to report adverse outcomes (for whatever reason) so little of it gets into the public domain. We know there is an issue with LASER based therapies in tattoo areas, and I have heard - anecdotally - a story like the one you tell here with e stim, but never seen it anywhere in the literature

I have just checked through the most recent detailed consideration - published in the Canadian Journal and although tattoo not specifically identified under the E Stim section it does say the following: "E stim should be applied only over healthy skin; therefore the intended electrode application area should be examined for lesions, signs of irritation and/or allergic reactions" (section 4.8 of the document - which is well worth reading). I KNOW that skin with a tattoo IS healthy, but it might not behave 'normally' - which could be the critical point?????

I would be interested to hear from others who have identified or experienced this issue so that we can be sure to consider it in future contraindication documentation - the more we share, the more accurate/responsive these docs will be

I am not aware of any contraindication document published in any country which currently identifies a tattoo as an issue (contraindication, precaution or danger) in the context of elec stim - maybe we should consider its inclusion???????

Tim

terry_redmond260 said:

luisef258 said:

Strange. Just for precaution you should check on the equipment.

Equipment was the first thing I checked, No shorts, recently replaced electrodes, Bioengineering technicians tests and certifies equipment every August, last time was checked was just one month ago. As clinic manager I also thought it was strange, so after checking the equipment I started to research the contents of Tattoo ink, it was surprising the conductive mediums in this ink, including carbon, Iron Oxide, arsenic, lead, and nickel. At my clinic we are now cautioning clients if they have tattoo's in the area of treatment.

This an example about the metal part of the INK: Tattoo-Induced Skin “Burn” During Magnetic Resonance Imaging in a Professional Football Player https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445217/

Thank you for sharing this on the forum. This is important to share with our colleagues worldwide.

luisef258 said:

Strange. Just for precaution you should check on the equipment.

Equipment was the first thing I checked, No shorts, recently replaced electrodes, Bioengineering technicians tests and certifies equipment every August, last time was checked was just one month ago. As clinic manager I also thought it was strange, so after checking the equipment I started to research the contents of Tattoo ink, it was surprising the conductive mediums in this ink, including carbon, Iron Oxide, arsenic, lead, and nickel. At my clinic we are now cautioning clients if they have tattoo's in the area of treatment.

Strange. Just for precaution you should check on the equipment.

Atlas of Illustrative Cases of Tattoo Complications. https://www.ncbi.nlm.nih.gov/pubmed/28288465

Guide to Treatment of Tattoo Complications and Tattoo Removal. https://www.ncbi.nlm.nih.gov/pubmed/28288463

I've find only this, and seems a good start: https://www.ncbi.nlm.nih.gov/pubmed/9514359

And just for curiosity https://www.ncbi.nlm.nih.gov/pubmed/28511186 https://www.ncbi.nlm.nih.gov/pubmed/28486229

Do understand that the well-recorded contraindications are based on adverse case reports. If someone did something harmfully, they may not be willing to share because of reputation or even legal concern. Therefore not many.

Now, most contraindications are based on scientific hypotheses, the true reliability is questionable. Just be as careful as possible. If you have done all the necessary screening and warning based on the best of your knowledge, then don't worry too much.

Last updated 11 months ago

Fisioniki289,

Thanks for your reply, but why is there nothing in the literature to advise us clinicians that there is a potential of burns?

Yes, the INK... often I warn patient and therapists about tattoo for laser, tecar, electrotherapy...