Modulation of the Toxicity of Three Red Tattoo Pigments by Artificial Aging.

Treatment of a refractory allergic reaction to a red tattoo on the lips with methotrexate and Q-switched Nd-Yag laser

As tattooing practices increase, delayed-type inflammatory reactions represent an uncommon adverse event to tattoo pigments. Different reaction patterns, such as eczematous, lichenoid, granulomatous and pseudolymphomatous reactions, have been previously reported, especially in association with metals contained in red tattoo pigments. We report a lichenoid papular reaction to an organic red tattoo ink, characterized by an intense mononuclear infiltrate dominated by CD8(+) T cells and CD56(+) lymphocytes and distributed in the superficial dermis around the red pigment and in the epidermis. Cytofluorimetric analysis of the lesional skin infiltrate confirmed the high frequency of cytotoxic CD8(+ )T cells and CD56(+)CD16(-) lymphocytes, most of which release type 1 cytokines. Chemical analysis of the red tattoo pigment confirmed its organic nature and the presence of intermediate reactive compounds. The lichenoid tissue reaction to red organic tattoo pigment showed the prototypical features of a cytotoxic inflammatory response to foreign substances (xenobiotics). The chemically unstable and reactive nature of modern tattoo pigments has to be taken into account by the clinician as well by the tattoo recipients.

Use of the alexandrite laser (755 nm, 100 nsec) for tattoo pigment removal in an animal model

Q-switched alexandrite laser treatment (755 nm) of professional and amateur tattoos

The application of facial cosmetic tattoos (eyeliner, lipliner, and rouge) has become popular over the past five years and has resulted in an increasing number of patients requesting removal of these permanent cosmetics. Poor positioning or misapplication of the tattoo pigment has been the most common reason for requesting removal. Because of the almost inevitable probability of scarring, removal of these facial tattoos has been difficult at best. We report the successful removal of facial cosmetic tattoos in ten different patients with the use of five different lasers. We have found the superpulsed CO2 laser and the Q-switched alexandrite laser to be effective in removal of black tattoo pigment. The alexandrite laser is effective without causing scarring, and the CO2 laser is extremely precise and provides the capability of removing tattoo pigment between eyelash or eyebrow hairs without damaging the hair follicles. Both the argon laser and the flashlamp pumped dye laser reacted with red tattoo pigment and offered some improvement but were not ideally suited for tattoo removal. However, the flashlamp pumped dye laser for pigment was very effective in removing red tattoo pigment possibly because of its short pulse width (300 ns) in addition to its appropriate wavelength. The combination of these three lasers (super-pulsed CO2, alexandrite, and flashlamp pigment lasers) is very effective in removing black and red (or shades thereof) facial tattoos. Caution must be taken to determine the presence of flesh-colored tattoo pigment, as this pigment (FE2O3) will reduce to black (FeO) upon laser impact.

A 21-year-old female presented with complaints of new-onset asymptomatic, erythematous plaques localized to the tattooed sites on her body. The patient had a history of psoriasis for the past three years. She initially had psoriatic plaques with a typical morphology in a generalized distribution present on the normal (nontattooed) skin which had resolved around three months ago. Around two months ago, she started developing erythematous plaques with minimal scaling localized to the tattooed sites. History revealed that the patient had gotten these tattoos two years ago. She did not recall any history of flare in psoriasis at the time of tattooing. Examination showed erythematous plaques localized to some areas of tattooed skin over the right forearm, leg, and left breast [Figure 1a-c]. Clinically, differential diagnoses considered were late-onset psoriatic koebnerization, granulomatous reaction secondary to tattoo ink, lichenoid tattoo reaction, and tattoo sarcoidosis.Figure 1: Cutaneous examination revealed decorative black ink tattoos with overlying erythematous plaques bearing fine whitish scales sharply confined to the tattooed areas over the right forearm (a), right leg (b), and left breast (c)Biopsy revealed a normal epidermis with dermal lymphohistiocytic infiltrate forming noncaseating granulomas with deposition of red pigment [Figure 2a and b].Figure 2: (a and b) Hist opathological examination of the affected area showed a normal epidermis with dermis displaying focal aggregates of lymphocytes, epithelioid histiocytes, and foreign body giant cells containing red tattoo pigment, findings consistent with foreign body granuloma (H and E, 40×) (a) and (H and E, 200×) (b). H and E = Hematoxylin and EosinANSWER: Granulomatous reaction secondary to tattoo ink Tattooing for cosmetic purposes has gained popularity in recent times. Cutaneous reactions to tattoos have generally been attributed to metallic salts used in the preparation of the pigment. Commonly reported reactions to tattoos can be divided into infections, allergic contact dermatitis to tattoo pigment, granulomatous reactions, lichenoid tattoo reaction, and localization of inflammatory skin conditions like psoriasis and eczema on the tattoo area.[1] Rarely, cutaneous skin conditions like pseudolymphomatous reactions and keratoacanthomas may develop. There have been a few case reports of exogenous pigments in the tattoo, inducing a sarcoidal granulomatous reaction presenting as a localized cutaneous disease or heralding systemic involvement.[2] Evolution of erythematous papules to scaly plaques localized to tattoo sites, presenting months to years after tattooing should raise suspicion of lichenoid reaction to tattoo, granulomatous reactions, and sarcoidal reactions.[3] These can be differentiated on the basis of histopathology. Multiple case reports of psoriasis showing isomorphic response localized to the tattoo sites with a delay of weeks to years after the tattooing process have also been reported. Most of these patients had a previous history of psoriasis, while a few were diagnosed with psoriasis after the appearance of koebnerization over tattoo sites.[4] Table 1 summarizes the clinical differentials in the above case along with the expected histopathological findings. Since our patient had a previous history of psoriasis, we had also kept the differential of late-onset koebnerization. However, there were no classical findings of psoriasis on histopathology. There was significant improvement within 4 weeks with topical mometasone furoate 0.1% cream. Steroids, laser therapy, and surgical excision have been considered in patients presenting with such tattoo.Table 1: Summarizes the clinical differentials in the above case along with the expected histopathological findingsIn suspected cases, especially in front of papulonodular lesions arising from a tattoo, it is important to perform an early diagnosis through histopathology. Key learning points Delayed Granulomatous Reactions to Tattoo PigmentsTattoo ink can incite granulomatous inflammation, often with noncaseating granulomas containing pigmentladen histiocytes—typically appearing months to years after tattooing. These reactions can mimic sarcoidosis and pose diagnostic challenges.Koebner Phenomenon in Psoriasis within TattoosIn individuals with psoriasis, Koebnerization can manifest at tattoo sites—even years after the procedure—resulting in psoriatic lesions localized to those areas.Therapeutic Approaches and Avoidance of Ink Dispersion InterventionsManagement often includes topical or systemic corticosteroids and, in some cases, antimalarials (e.g., hydroxychloroquine). Declaration of patient consent The authors certify that they have obtained all appropriate patient consent. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Ornamental tattooing involves the administration of exogenous pigments into the skin to create a permanent design. Our case focuses on a 62-year-old woman who presented with an inflamed enlarging nodule on her right proximal calf, which arose within the red pigment of an ornamental tattoo. The nodule was diagnosed as squamous cell carcinoma (SCC) and subsequently excised. Over the course of the following year, the patient was diagnosed with a total of five additional SCCs that also arose within the red pigment of the tattoo. The increased popularity of tattooing and the lack of industry safety standards for tattoo ink production, especially metal-laden red pigments, may lead to more cases of skin cancer arising within tattoos among patients of all ages.

The introduction of pigments or dyes during tattooing may trigger various histological types of hypersensitivity reaction, mainly lichenoid, granulomatous, sarcoidosis-like, pseudolymphomatous and eczematous (1). The time of appearance of these reactions is highly variable, from immediately after tattooing to 45 years later (2). We report here an unusual case of dermal sclerosis restricted to the red part of tattoos. Such “scleroderma-like” reactions have been reported on very few occasions (3, 4). CASE REPORTAn otherwise healthy 47-year-old woman presented for an inflammatory infiltration of an ankle tattoo, which had become symptomatic almost immediately after tattooing. Eighteen months earlier, a yellow, orange, red, white and black “sacred heart” had been tattooed on her ankle in a professional tattoo parlour (Fig. 1A). Within the first week, she noticed unusual swelling and delayed healing. Pruritus had been intense, with a severe impact on daily living and sleep for the past 18 months. This episode was the first she had reported after tattooing, as she had been tattooed three times pre-viously without complication. However, a concomitant itchy reaction had also developed at this time on the red part of another tattoo located in the lumbar area, which had been drawn by the same artist with the same red ink 6 months before the “sacred heart”. Both reactions had remained stable without improvement. She refused to apply any corticosteroid ointment during this time. Examination of the 18-month-old tattoo showed an inflamed, squamous and indurated infiltration confined to the red parts. Several exulcerations were noted over the red area (Fig. 1B). Physical examination was other-wise normal, with no sign of systemic scleroderma. The clinical features were suggestive of a red tattoo pigment hypersensitivity reaction. Histological examination of a 4-mm punch biopsy of the red tattoo revealed a lichenified epidermis with com-pact hyperkeratosis, hypergranulosis and acanthosis. An inflammatory sclerosis was located in the superficial and mid-dermis with thickened and homogenized collagen bundles, lymphocytes and macrophages. Exogenous red tattoo pigments were localized around mid-dermal vessels free in the dermis or in macrophages. Focal lichenoid reaction was observed (Fig. 2). The features were not indicative of localized scleroderma. A diagno-sis of dermal sclerosis related to a chronic inflammatory reaction to the red pigment was suspected. No test could be performed on the culprit red ink as the manufacturer did not reply to our request for a sample or information on its composition. Betamethasone dipropionate 0.05% ointment was applied daily for a month and then tapered slowly over 3 months. Pruritus resolved within a week and lesions improved within the first 2 months. After 3 months, no inflammation was noted. We suggested that the patient avoid further tattooing with any type of red ink in the absence of identified components. She had two new tattoos done with various colours (yellow, green, blue, orange, pink, violet, brown and black) without complication. However, one of them was a pink cat with red ink from a different manufacturer applied for the nose. Pruritus occurred on that very location after tattooing, but no recall reaction occurred elsewhere. She and her tattooist have decided to stop using red ink.DISCUSSIONWe report here an unusual and severe “scleroderma-like” reaction after tattooing, which was restricted to the red parts of a tattoo. Symptoms of hypersensitivity reaction to tattoo pigments are often non-specific, including discomfort, swelling, papules or nodules and pruritus (5). Clinical induration is not an uncom-mon manifestation of tattoo reactions (5), but the

Excerpt Allergic reactions to tattoo pigments are infrequently seen. Previous investigators reporting reactions to red tattoo pigment (mercuric sulfide) claim mercury-containing ointments or immuni...

Aim: Tattoo pigments are deposited in the skin and known to distribute to regional lymph nodes. Tattoo pigments are small particles and may be hypothesized to reach the blood stream and become distributed to peripheral organs. This has not been studied in the past. The aim of the study was to trace tattoo pigments in internal organs in mice extensively tattooed with 2 different tattoo ink products. Material/Methods: Three groups of mice were studied, i.e., 10 tattooed black, 10 tattooed red, and 5 untreated controls. They were tattooed on the entire back with commercial tattoo inks, black and red. Mice were sacrificed after 1 year. Samples were isolated from tattooed skin, lymph nodes, liver, spleen, kidney, and lung. Samples were examined for deposits of tattoo pigments by light microscopy and transmission electron microscopy (TEM). Results: TEM identified intracellular tattoo pigments in the skin and in lymph nodes. TEM in both groups of tattooed mice showed tattoo pigment deposits in the Kupffer cells in the liver, which is a new observation. TEM detected no pigment in other internal organs. Light microscopy showed dense pigment in the skin and in lymph nodes but not in internal organs. Conclusion: The study demonstrated black and red tattoo pigment deposits in the liver; thus, tattoo pigment distributed from the tattooed skin via the blood stream to this important organ of detoxification. The finding adds a new dimension to tattoo pigment distribution in the body, i.e., as observed via the blood in addition to the lymphatic pathway.

Q-switched lasers are commonly used to achieve tattoo removal, utilizing the principle of selective photothermolysis. However, certain tattoo pigments may darken following laser pulsing. To determine whether this side effect can be used to therapeutic advantage in a woman who previously had her eyebrows enhanced with a dark tattoo that spontaneously changed to a reddish hue over time. The woman's eyebrows were pulsed with the Q-switched Nd:YAG laser at both 532 nm and 1064 nm. The test areas pulsed with the 1064 nm laser revealed partial clearing. However, 532 nm Q-switched Nd:YAG pulses produced darkening of tattoo pigment both at the test sites and in the subsequent treatment. Q-switched lasers can produce darkening of red tattoo pigment. In some cases this side effect can be used to therapeutic advantage.

Systemic contact dermatitis to a surgical implant presenting as red decorative tattoo reaction

Granulomatous reactions to tattoo ink are most commonly associated with mercury sulfide, a component of red pigments. Treatment options show limited results. Allopurinol, an inhibitor of xanthine oxidase, has been reported as a successful alternative treatment to granulomatous disorders, such as sarcoidosis and granulomatous reactions to fillers and tattoos. We report a case of granulomatous reaction to red tattoo pigment treated with allopurinol for 6months. Good clinical improvement could be noticed during this time. Two months after we stopped the treatment, the lesion recurred. Allopurinol emerges as an important drug for the management of granulomatous reactions caused by tattoo pigments. Based on the significant clinical improvement noticed during its use, we recommend new studies to elucidate all the potential benefits of the use of allopurinol for the treatment of granulomatous reactions to tattoo ink.

Multisystemic Granulomatosis Induced by Red Tattoo Pigment: Course Over 10 Years

Considering the ever increasing popularity of tattoos, significant reactions remain unusual. Red pigments are the commonest cause of delayed tattoo reactions. Histology typically shows extensive lichenoid basal damage, well away from the dermal pigment. We report two cases of lichenoid reactions to red tattoo pigment and review the literature on the subject.