Lichenoid tattoo reaction responding to topical tacrolimus ointment

Abstract

Conflict of interest: none declared. A 51‐year‐old man had four tattoos applied to his skin between 1996 and 2001. The first, on his right anterior chest wall, was drawn by a different artist from the other three, which were sited on the left anterior chest wall, the proximal right lower leg and the distal right lower leg, in 1997, 2000 and 2001, respectively. The constituent parts of the dyes used were not known. Within weeks of shaving the hair overlying the leg tattoos, the patient developed severe itching, irritation and associated thickening of the red‐coloured areas of the tattoos (Fig. 1a). Similar but intermittent symptoms arose in the left chest tattoo, while that on the right, by the other artist, remained quiescent. Patch tests to the European standard series and mercury were negative but the patient reacted to disperse blue dyes 106 and 124 at 96 h. Baseline biopsy showed hyperkeratosis and a dense dermal inflammatory cell infiltrate comprising mainly lymphocytes in keeping with a lichenoid reaction. Potent topical steroid treatment was of limited and short‐lived benefit. A trial of topical tacrolimus ointment (0.1%) dramatically relieved his intense itching and after daily application for 3 months, there was evidence of flattening of the thickened red‐dye areas (Fig. 1b). Repeat biopsy after this interval showed histological improvement, with a normal epidermis and a moderate dermal inflammatory cell infiltrate, in keeping with an ongoing hypersensitivity reaction to the tattoo pigment.