Photo with a tattoo or mark that identifies the patient

When people think about privacy, most think about the eyes. That is why the black bar over the eyes became the symbol of the "anonymous" photo. But anyone who knows the patient will recognize a tattoo on the nape, a scar on the chin or a mole beside the nose in a second. In small areas of the face, distinctive features identify a person more than the eyes themselves.

This page covers how to handle those marks: what must stay in the chart, what can be covered or cropped for teaching, publication or promotion, and how to do it without creating a misleading image.

What identifies the patient besides the face?

The LGPD (Brazil's data protection law) treats as personal data any information related to an identified or identifiable person, and health images fall under sensitive personal data. Identifiable means "someone could recognize them," and that depends on context. In practice, the marks that identify most often are:

• tattoos, even small ones, on the face, neck, nape or behind the ear;
• very specific scars, moles, spots and freckles;
• piercings and holes in the ear, nose, eyebrow and lip;
• haircut, colored streaks, eyebrow design, beard;
• glasses, earrings, necklace and clothing;
• the background: sign, painting, window, a distinctive wall;
• the caption: age, profession, city, event.

Anonymization only holds when none of this leads back to the person. Facial biometric data adds another point: the face itself can be recognized by automated systems, which reinforces the need for care with published images.

What to do in the chart?

In the chart, the photo stays intact. The goal is to document the patient as they are, and covering a tattoo or erasing a mark removes information from the record. The care needed here is different: control who has access, where the file is stored and for how long, as in storing patient photos and retaining photos in the chart.

If the mark is in the treated area, it must be visible in the record: it is a reference point for comparing before and after, and it helps confirm that both photos are of the same patient.

What to do for publication, teaching or promotion?

For any use outside the chart, the path is to crop or cover what identifies the person and to have specific authorization for that use, as in separate consent for publishing images. Even with authorization, the safe practice is to show only what is necessary.

Cropping is better than the black icon, because it does not draw attention to what is hidden. If you use a bar, fill it with a neutral color and make it clear on the slide or in the caption that the image was edited to protect identity.

How to avoid a misleading image?

Covering a tattoo with the same color as the skin can look like an edit of the image and raise doubts about the result. The rule is: no retouching that changes the clinical appearance. If the edit is meant to protect identity, it must be visible and declared ("bar applied to preserve identity"). If you are unsure between cropping and editing, crop. The page to edit or not to edit a clinical photo covers the limit, and phone filters and beautification shows why retouching is not an option.

What if the patient wants the tattoo to show?

It can happen: the patient is proud of the tattoo and does not mind it showing. Even so, the rule of conduct is the same: what they authorize must be in writing, and the authorization must state that the mark will appear. People change their minds, and a tattoo in the photo of a published case is hard to take back. When in doubt, crop.

How do publication and simulation fit together?

Publishing real photos must follow what can be published (CFO and CONAR), according to the rules of your professional council in Brazil. A simulation image, on the other hand, is never presented as a result, as described in illustrative simulation.

What mistakes to avoid?

• Thinking that covering the eyes is enough.
• Covering the tattoo in the chart and losing the record.
• Editing the image without declaring the edit.
• Forgetting the background, earrings and caption.
• Publishing without specific authorization because "no one could recognize them."

The question that organizes everything: if a friend or colleague saw this image, would they recognize the person? If the answer is maybe, crop more.