TATTOO

By Gary M. White, MD

Approach to patients with Tattoo Reactions

The differential for a patient who presents soon after tattoo placement with an inflammatory, eczematous reaction includes:

Condition Typical time frame and comments
Irritant contact dermatitis 0-1 week. From the skin puncturing and chemicals used. Resolves 1-2 weeks
Atypical mycobacteria infection 1-2 weeks (but can be up to 5 months). May localize to gray areas
Allergic contact dermatitis Weeks to 17 years after placement. Selectively affects one color

It would seem reasonable in diagnostically uncertain cases to temporize with a topical steroid for 1-2 weeks and see if the changes resolve. If not, reevaluation, a biopsy and culture if necessary would be in order. Of note, non-specific, minor complaints of skin elevation and itching often provoked by the sun are common even 3 months or more after tattoo placement [JEADV 2013;27;846].

For any nodular, indurated lesions that could represent allergic contact dermatitis, pseudo lymphoma, sarcoidal granuloma, sarcoidosis, etc. a biopsy would seem prudent at any time.

Allergic Contact Dermatitis

Allergic Contact Dermatitis to Tattoo
Allergic Contact Dermatitis to Tattoo

Infection

Acid-Fast Bacilli Infection of a Tattoo. Days to weeks after placement of a tattoo, infection, often caused by atypical mycobacteria, may present.
Acid-Fast Bacilli Infection of a Tattoo

Bacterial Infection, e.g., furunculosis

Molluscum Contagiosum

Granuloma

Granulomas may develop within a tattoo in a patient without any evidence of any systemic granulomatous disease (e.g. sarcoidosis) [AD 1962;86;287]. These may represent foreign body granulomas.

Moles and Melanoma

Moles commonly and melanoma uncommonly arise within tattoos. Thus, any skin exam is not complete without a thorough exam of the any tattoos. The irregular pigmented lesion below on biopsy was a benign mole.
Bening mole in a tattoo

Melanoma may occur in a tattoo [Acta Derm Venereol 2014; 94: 325–326]

Pyoderma Gangrenosum

Tattoo immediately after completion and ulcerative pyoderma gangrenosum localized to the red-dye portion of the tattoo (in a woman with regional enteritis). From CMAJ. 2014 Sep 2; 186(12): 935.

Sarcoidosis

Sarcoidosis has initially manifested itself as nodular skin lesions localized to either single or multiple colors within a tattoo. Patients may have a negative systemic workup only to later develop sarcoidosis. The tattoo may be affected soon after placement or up to 45 years later. In the case below, thickened skin developed in the areas of dark pigment. The third image is impressive clearing after treatment with minocycline and hydroxychloroquine. From Dermatology Online Journal 2014;20;8.

Sarcoidal granulomas may also develop if the patient is allergic to any of the component metals, e.g., nickel, cobalt [JAAD 2006;55:S71].

Sparing

Leukocytoclastic vasculitis sparing a tattoo. From JAAD Case Reports September 2015 Volume 1, Issue 5, Pages 269–271.

Squamous Cell Carcinoma

SCC and multiple eruptive KAs, BCC and melanomas have developed in tattoos [J Cutan Med Surg. 2016 Sep 13]. SCC/KAs are the most common and are most frequently associated with red tattoo ink [Dermatol Surg. 2015 Oct;41:1190].

Multiple KAs developing in a new tattoo.
picture here picture here

Verrucous

Verrucous or pseudoepitheliomatous hyperplasia occurring in red tattoo pigment has been reported various times [J Clin Aesthet Dermatol. 2015 Dec; 8(12): 48–52]. In some of these patients sun-exposure seemed to trigger the reaction. Histologically, it resembles hypertrophic lichen planus. Treatments have included topical and intralesional steroids as well as excision.

Miscellaneous

DLE, keratoacanthomas, and pseudolymphomatous reactions have developed in tattoos. Inflammatory reactions within and outside of the tattoo soon after placement have been reported [Dermatology Online Journal 22(7)].

Gunpowder Tattoo
gunpowder tattoo in the skin of the hand.

Tattoo Removal

For removal of unwanted tattoos, surgical excision (staged if needed) or laser treatment (e.g., ruby, alexandrite, Nd:YAG) may be done. The Q-switched Nd:YAG laser at 1064 nm or the Q-switched ruby laser are effective at eliminating amateur or professional tattoos, particularly black pigment. Lasers which have been shown effective at removing red tattoo pigment include the Q-switched Nd:YAG at 532 nm and the green light flashlamp-pumped pulsed dye laser at 510 nm. Green tattoo pigment is harder to removed than other colors [JEADV 2017;31;904].

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