Tattoo Reactions Research Articles

Ablative laser surgery for allergic tattoo reactions: a retrospective study

Patients with allergic tattoo reactions are burdened with itch and have a reduced quality of life. Conservative treatment is often insufficient and little is known about treatment options to remove the responsible allergen. We aimed to address the effectiveness and safety of ablative laser therapy including measurement of patient’s satisfaction, in patients with allergic reactions to tattoos. A retrospective study was conducted including patients with allergic tattoo reactions who were treated with a 10,600 nm ablative CO2 laser, either by full-surface ablation or fractional ablation. Clinical information originated from medical files and a 25-item questionnaire. Sixteen tattoo allergy patients were treated with a CO2 laser between January 2010 and January 2018. Fourteen patients completed the questionnaire. Ten patients were satisfied with laser treatment. On a visual analogue scale, pruritus and burning improved with a median of 5.5 and 4 points in the full surface ablation group and 3 points on both parameters in the fractional ablation group. Despite the relatively small group of patients, our results suggest that CO2 laser ablation improves itching, burning and impact on daily life in tattoo allergy.

由文眉处反应诊断系统性结节病一例

由文眉处反应诊断系统性结节病一例

Tattoo allergy. Can we identify the allergen?

Allergic reactions in tattoos and permanent make-up are rare but they could be problematic. The clinical presentation and the histopathology are diverse and often confusing. Symptomatic treatment is frequently unsuccessful and invasive techniques can be required. Patch testing to identify the causative allergen is disappointing. The composition of the inks is complex; organic and inorganic colorants, auxiliary components and by-products must be considered. Physical factors such as ultraviolet and laser irradiation could play a role in haptenization of colorants in the skin. Clinical observation and advanced diagnostic methods can be helpful in the diagnosis. Preventive systematic skin testing with tattoo inks, apart from being time-consuming and expensive, is useless.

Histopathology of Red Tattoo Reactions.

Despite popularity of tattoos, complications may occur. In particular, red tattoo reactions due to allergic reactions are the most frequent chronic tattoo reactions. However, little is known about its histopathology and underlying pathomechanisms. The aim of this article is to analyze the histopathology of red tattoo reactions for diagnostic purposes and to acquire more insight into pathogenesis. A retrospective cross-sectional study was conducted by reviewing the histopathology of 74 skin biopsies of patients with allergic red tattoo reactions. Histopathological findings, such as inflammation patterns, inflammatory cells and pigment depth and color, were semi-quantified with an in-house validated scoring system by 2 independent senior investigators. Histiocytes and lymphocytes were both present in >93%. Histiocytes were the predominant inflammatory cells in 74.3%, but well-defined granulomas were mostly absent (78.0%). Eosinophils were uncommon (8.1%) The predominantly histiocytic reaction combined with interface dermatitis was the main inflammation pattern (37.9%). Most biopsies showed more than one reaction pattern. Interface involvement was observed in 64.8%, despite the intended depth of standard tattoo procedures, in which pigment is placed deeper, in the upper- and mid-dermis. Statistical analyses showed a significant association between inflammation severity and pigment depth (P = 0.024). In 6 cases (8.1%) pigments could not be retrieved histologically. In this cohort we demonstrated that cutaneous reactions to red tattoo ink are frequently characterized by the combination of dermal predominantly histiocytic infiltrates and epidermal interface dermatitis. Allergic reactions to red tattoo pigments probably represent a combination of a subtype IVa and IVc allergic reaction. Clinicians should be aware of the specific histopathology of these reactions and therefore the importance of taking a diagnostic skin biopsy.

Delayed Tattoo Reaction From Red Dye With Overlapping Clinicopathological Features: Examination With High-Frequency Ultrasound and Line-Field Optical Coherence Tomography.

Delayed Tattoo Reaction From Red Dye With Overlapping Clinicopathological Features: Examination With High-Frequency Ultrasound and Line-Field Optical Coherence Tomography.

Tattoo pigment agglomerates measured in skin biopsies by computerised light microscopy

Black tattoo reactions are suggested to be foreign body reactions manifested as papulo-nodular inflammation that is associated with active sarcoidosis. To study the morphology of black and red pigment agglomerates in skin biopsies from tattoo reactions, referenced to clinical diagnoses. Agglomerate count, area, width, height, circumference and circularity were measured in 161 patients by light microscopy (Olympus BX51™); 161 unstained skin biopsies from 64 black tattoo reactions and 97 reactions in red tattoos with allergy. Images (Jenoptic Gryphax RGB camera) were taken through a 40× objective using immersion oil. Computerised analysis of agglomerates was performed using ImageJ software. Student t test, chi-square test, Fisher Exact test, ANOVA and Bonferroni tests were applied. Comparison of black and red pigment agglomerates showed no overall differences in count, area, width, height or circumference. However, in black tattoo reactions, the count of agglomerates was higher in patients with sarcoidosis (P=.009) vs no sarcoidosis. Black agglomerates were more circular shaped as compared to red, P=.023. In red tattoo reactions, agglomerates in patients with allergic cross-reactivity were slightly more circular (P=.036) vs patients with milder allergy. The count of red agglomerates was lower in patients clinically typed excessive hyperkeratosis (P=.041) compared with other clinical types of allergy. Patients with reactions in black tattoos associated with sarcoidosis have increased count of pigment agglomerates vs those without associated sarcoidosis indicating that black pigment agglomeration is one among a number of factors triggering sarcoid tattoo complication. Circular shape of agglomerates may code for bioactivity.

Identification of pigments related to allergic tattoo reactions in 104 human skin biopsies.

BackgroundRed tattoos are prone to allergic reactions. The identity of the allergen(s) is mostly unknown.ObjectivesChemical analysis of human skin biopsies from chronic allergic reactions in red tattoos to identify culprit pigment(s) and metals.Material and methodsOne hundred four dermatome biopsies were analyzed by matrix‐assisted laser desorption/ionization tandem mass spectrometry (MALDI‐MS/MS) for identification of commonly used organic pigments. Metal concentrations were assessed by inductively coupled plasma (ICP)‐MS and x‐ray fluorescence (XRF). Fourteen patients had cross‐reactions in other red tattoos.ResultsIn total, the identified pigments were mainly azo Pigment Red (P.R.) 22 (35%), P.R. 210 (24%), P.R. 170 (12%), P.R. 5 (0.9%), P.R. 112 (0.9%), and Pigment Orange (P.O.) 13 (11%). P.R. 122 (0.9%) and Pigment Violet (P.V.) 23 (8%) were also common. P.R. 22, P.R. 170, and P.R. 210 also dominated in patients with cross‐reactions. In 22% of the biopsies, no red pigment was detected. Element analysis indicated the presence of the sensitizers nickel and chromium.ConclusionsP.R. 22, P.R. 170, and P.R. 210 were identified as the prevailing pigments behind chronic allergic reactions in red tattoos. The epitope causing the reaction might be a pigment‐degradation product. Metal contamination may derive from different sources, and its role in red tattoo allergy cannot be ascertained.

Quantification of cutaneous allergic reactions using 3D optical imaging: A feasibility study

BackgroundUser‐independent quantitative measures of cutaneous allergic reactions can help the physicians manage and evaluate the treatment of cutaneous allergic reactions. In this paper, we present and validate a method to quantify the elevation, volume and area of cutaneous allergic reactions to red tattoos.MethodsThe skin surface of allergic tattoo reactions was imaged using an optical 3D scanner. The in‐house developed analysis tool measured the elevation, volume and area of the lesions, compared to a reference surface. This reference surface was created by 3D interpolation of the skin after manual removal of the lesions. The error of the interpolation tool was validated using a digital arm model. The error of our optical scanner was determined using a 3D printed lesion phantom. The clinical feasibility of the method was tested in 83 lesions in 17 patients.ResultsThe method showed clear potential to assess skin elevation, volume change and area of an allergic reaction. The validation measurements revealed that the error due to interpolation increases for larger interpolation areas and largely determined the error in the clinical measurements. Lesions with a width ≥4 mm and an elevation ≥0.4 mm could be measured with an error below 26%. Patient measurements showed that lesions up to 600 mm2 could be measured accurately, and elevation and volume changes could be assessed at follow‐up.ConclusionQuantification of cutaneous allergic reactions to red tattoos using 3D optical scanning is feasible and may objectify skin elevation and improve management of the allergic reaction.

Lichenoid granulomatous dermatitis revisited: A retrospective case series

Lichenoid granulomatous dermatitis (LGD) is an uncommon reaction pattern for which clinical correlates can be difficult to establish. LGD combines vacuolar degeneration with variable types of granulomas. To determine clinical correlates of LGD. The laboratory information systems at the University of Florida, the Medical College of Wisconsin, and Inform Diagnostics Research Institute were queried to identify 56 cases of LGD. Cases were reviewed for information regarding eosinophils, plasma cells, deep perivascular infiltrates, granuloma subtype, parakeratosis, epidermal atrophy, psoriasiform epidermal changes, pseudoepitheliomatous hyperplasia, periadnexal inflammation, vasculitis, and red blood cell extravasation. The most common clinical correlates were drug eruption (39.3%, n=22) and lichenoid keratosis (19.6%, n=11). Tattoo reaction, postherpetic dermatitis, and scabies or postscabietic dermatitis each accounted for 7.1% (n=4) of cases. Pigmented purpuric dermatosis and lichen striatus each accounted for 5.4% (n=3) of cases. Dermal eosinophils (P=.005) and psoriasiform epidermal changes (P=.055) were associated with drug hypersensitivity. Perineural (P=.049) and perifollicular (P=.003) inflammation were associated with tattoo reaction and postherpetic dermatitis. Red blood cell extravasation was helpful in cases of pigmented purpuric dermatosis (P=.049). This study is limited by its retrospective nature and statistical power. Dermal eosinophilia, psoriasiform epidermal changes, periadnexal inflammation, and red blood cell extravasation might aid in the clinical diagnosis of patients with LGD.

Tattoos and skin barrier function: Measurements of TEWL, stratum corneum conductance and capacitance, pH, and filaggrin.

Initially after tattooing, the skin barrier function is broken. However, the long-term impact of clinically healed tattoos on this has never been studied. The aim was to investigate the long-term effect on the skin barrier function in normal tattoos and examples of tattoos with chronic inflammatory complication. Participants were recruited from the "Tattoo clinic" of the Dermatological Department on Bispebjerg Hospital in Denmark, where patients with complicated tattoo reactions are treated. Transepidermal water loss (TEWL), conductance, capacitance, and pH were measured in tattooed skin with regional control measurements in normal non-tattooed skin. Natural moisturizing factor (NMF) was measured in collected tape strips. Twenty six individuals with 28 tattoos were included, that is, 23 normal tattoos without any pathologic reaction and 5 tattoos with chronic inflammatory complications. No significant differences were found in tattooed versus non-tattooed skin with respect to TEWL (median values 6.6 vs 7.2g/m2 /h), conductance (76 vs 78a.u.), pH (5.94 vs 5.79), and NMF (0.58 vs 0.59mmol/g protein). Capacitance (64 vs 57a.u.) was higher in tattooed skin compared to non-tattooed skin (P=0.006). Similar results were found in tattoos with inflammatory reactions. Overall, skin tattoos do not affect the long-term skin barrier function markedly. The skin capacitance was, however, affected in tattooed skin areas compared to non-tattooed skin areas.

Tattoo reactions as the initial presentation of lepromatous leprosy and cutaneous sarcoidosis: Report of two cases

There has been a rising trend of tattooing in the recent years, resulting in an increased incidence of cutaneous adverse effects. A wide range of infectious and noninfectious dermatoses have been described to occur within tattoos. Cutaneous complications developing in tattooed skin as the initial manifestation of the disease are uncommon. We describe two interesting cases with black tattoo-related reactions as the presenting feature of lepromatous leprosy and cutaneous sarcoidosis, respectively.

Tattoo-associated complications and related topics: A comprehensive review

As tattoos become more common, it is likely that practitioners will encounter adverse tattoo reactions with increasing frequency. While some tattoo-related complications (TRCs) may be nonspecific and challenging to diagnose, others present overtly and can be identified quickly by a well-informed practitioner. TRCs occur at both of these extremes, highlighting the need for better awareness and knowledge sharing regarding this heterogeneous group of morbidities. This review is a result of a compilation of the best available clinical evidence across various groupings of TRCs. The authors' intent was to provide the reader with a comprehensive overview of the topic while creating a rich repository of referenced knowledge for future investigations. From the standpoint of frontline health-care providers, effective recognition and management of TRCs require an open-mind, high degree of clinical suspicion, and nonjudgmental approach to a mainstream phenomenon that is still considered by many to be a taboo. The following core competencies are addressed in this article: Medical knowledge, Patient care, and Systems-based practice.

Granulomatous tattoo reactions in permanent makeup of the eyebrows.

Journal of Cosmetic DermatologyVolume 18, Issue 1 p. 212-214 EDITORIAL ECHO Granulomatous tattoo reactions in permanent makeup of the eyebrows Sanne Huisman MD, Corresponding Author Sanne Huisman MD [email protected] orcid.org/0000-0003-0514-3011 Academic Tattoo Clinic Amsterdam, Department of Dermatology, VU University Medical Centre, Amsterdam, The NetherlandsSearch for more papers by this authorSebastiaan A. S. van der Bent MD, Sebastiaan A. S. van der Bent MD Academic Tattoo Clinic Amsterdam, Department of Dermatology, VU University Medical Centre, Amsterdam, The NetherlandsSearch for more papers by this authorAlbert Wolkerstorfer MD, PhD, Albert Wolkerstorfer MD, PhD Academic Tattoo Clinic Amsterdam, Department of Dermatology, Academic Medical Centre, Amsterdam, The NetherlandsSearch for more papers by this authorThomas Rustemeyer MD, PhD, Thomas Rustemeyer MD, PhD Academic Tattoo Clinic Amsterdam, Department of Dermatology, VU University Medical Centre, Amsterdam, The NetherlandsSearch for more papers by this author Sanne Huisman MD, Corresponding Author Sanne Huisman MD [email protected] orcid.org/0000-0003-0514-3011 Academic Tattoo Clinic Amsterdam, Department of Dermatology, VU University Medical Centre, Amsterdam, The NetherlandsSearch for more papers by this authorSebastiaan A. S. van der Bent MD, Sebastiaan A. S. van der Bent MD Academic Tattoo Clinic Amsterdam, Department of Dermatology, VU University Medical Centre, Amsterdam, The NetherlandsSearch for more papers by this authorAlbert Wolkerstorfer MD, PhD, Albert Wolkerstorfer MD, PhD Academic Tattoo Clinic Amsterdam, Department of Dermatology, Academic Medical Centre, Amsterdam, The NetherlandsSearch for more papers by this authorThomas Rustemeyer MD, PhD, Thomas Rustemeyer MD, PhD Academic Tattoo Clinic Amsterdam, Department of Dermatology, VU University Medical Centre, Amsterdam, The NetherlandsSearch for more papers by this author First published: 10 April 2018 https://doi.org/10.1111/jocd.12540Citations: 15Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume18, Issue1February 2019Pages 212-214 RelatedInformation

Tattoo reaction: Case series

Tattoo reaction: Case series

Treatment of red tattoo reaction using CO2 laser.

Treatment of red tattoo reaction using CO2 laser.

Cutaneous Complications Related to Tattoos: 31 Cases from Finland

Background: Cutaneous complications related to permanent tattoos affect 2-30% of those patients who have tattooed their skin. Little is known about the cases of tattoo complications in Finland. Objective: The aim of this study was to conduct a retrospective review of a series of Finnish patients with cutaneous tattoo reactions. Methods: We collected cases of tattoo reactions from the Department of Dermatology at Helsinki University Central Hospital, from members of the Finnish dermatological society and from various other sources (author's private practice, tattooists, professional internet forum). We analysed the demographics, clinical presentation, diagnosis, and microscopic findings on the skin biopsies, and evaluated the therapeutic outcome. Results: Thirty-one patients (16 men and 15 women, mean age 37.8) were included from 9 cities, mainly from Helsinki. Fifty-two percent (16/31) presented with an allergic tattoo reaction mainly against the red colour (75%, 12/16). Reactions were clinically polymorph ranging from scattered papules or nodules to complete infiltration of a colour. Lesions were itchy and sometimes painful. The reactions were lichenoid, granulomatous, pseudolymphomatous or less specific with a dermal lympho-histiocytic or plasmocytic infiltrate. Other diagnoses included tattoo blow-out (13%), melanoma within a tattoo, naevi within a tattoo (10% each), lichen planus (6%), granulomatous reaction with uveitis, sarcoidosis and dermatofibroma (3% each). Allergic tattoo reactions were mainly treated with local corticosteroid (CS) ointments, CS infiltration or surgical removal. Conclusion: This review is the largest series of tattoo complications in the Baltic area. It illustrates the wide spectrum of complications. Prospective, controlled therapeutic studies are necessary to assess the best treatment protocols for tattoo allergies and tattoo reaction management in general.

Papulo-Nodular Reactions in Black Tattoos as Markers of Sarcoidosis: Study of 92 Tattoo Reactions from a Hospital Material

Background/Aims: Sarcoidosis is, from historical data, suggested to be more prevalent among patients with tattoo reactions. We aimed to evaluate this association in a systematic study. Methods: This is a consecutive study of patients with tattoo complications, diagnosed in the “Tattoo Clinic” at Bispebjerg University Hospital in Copenhagen, Denmark, from 2008 to 2015, based on clinical assessment and histology. From the overall group of 494 tattoo complications in 406 patients, 92 reactions in 72 patients showed a papulo-nodular pattern studied for local and systemic sarcoidosis, since sarcoidosis is expected to be nodular. Results: Of the 92 reactions with a papulo-nodular pattern, 27 (29%) reactions in 19 patients were diagnosed as cutaneous or systemic sarcoidosis, supported by histology; 65 (71%) were diagnosed as non-sarcoidosis due to histology and no clinical sarcoid manifestations. “Rush phenomenon” with concomitant reaction in many other black tattoos, triggered by a recent tattoo with a papulo-nodular reaction, was observed in 70% in the sarcoidosis group and 28% in the non-sarcoidosis group, indicating a predisposing factor which may be autoimmune and linked with sarcoidosis. Agglomerates of black pigment forming foreign bodies may in the predisposed individual trigger widespread reaction in the skin and internal organs. Conclusion: Black tattoos with papulo-nodular reactions should be seen as markers of sarcoidosis. Papulo-nodular reactions may, as triggers, induce widespread reactions in other black tattoos - a “rush phenomenon” - depending on individual predisposition. Sarcoidosis is estimated to be 500-fold increased in papulo-nodular reactions compared to the prevalence in the general population, and the association with black tattoos is strong.

Surgical Treatment of Tattoo Complications.

With a continuing increase in the number of tattoos performed worldwide, the need to treat tattoo complications is growing. Earlier treatments of chronic inflammatory tattoo reactions were dominated by a medical approach, or with no active intervention. In this chapter, we will address modern surgical approaches applied to situations when medical treatment is inefficient and lasers are not applicable. Dermatome shaving is positioned as first-line treatment of allergic tattoo reactions and also indicated in a number of other tattoo reactions, supplemented with excision in selected cases. The methods allow fundamental treatment with removal of the culprit pigment from the dermis. The different instruments, surgical methods, and treatment schedules are reviewed, and a guide to surgeons is presented. Postoperative treatments and the long-term outcomes are described in detail. An algorithm on specialist treatment and follow-up of tattoo reactions, which can be practiced in other countries, is presented.

Guide to Treatment of Tattoo Complications and Tattoo Removal.

Clinicians in the fields of general medicine, dermatology, and plastic surgery are in their work now and then confronted with tattoo complications. Recognizing the rather few important diagnostic groups and urgencies, the medical 'decision tree' of treatment becomes quite simple. Acute conditions are dominated by bacterial infections needing antibiotic treatment. Systemic infection is a matter of urgency and requires intravenous treatment in a hospital without delay to prevent septic shock. Inflammatory reactions are a real challenge. Chronic allergic reactions in red tattoos are mostly nonresponsive to topical corticoid and best treated with dermatome shaving with complete removal of the hapten concentrated in the outer dermis. Laser treatment of allergic reactions can boost the allergy with worsening and a potential risk of anaphylaxis and is thus not recommended in tattoo allergy. Chronic papulonodular reactions in black tattoos with pigment agglomeration can respond to local corticoid or be treated with dermatome shaving or lasers depending on availability. It is important to recognize sarcoidosis, which is strongly associated with reactions in black tattoos. Tattoo complications also include many rare but specific entities, which require individual treatment depending on the case and the disease mechanism. Removal of tattoos in individuals regretting their tattoo is performed using Q-switched nanosecond lasers and the recently introduced picosecond lasers. In view of the various tattoo pigments with different absorption spectra and the limited number of laser wavelengths, it is difficult to predict treatment outcome, and it is recommended to pretreat small test spots. Black and red colors are removed best, while other colors are difficult. Removal of large tattoos, especially when multicolored, is hardly achievable and not recommended. Clients often have unrealistic expectations, and informed consent and dialogue between the client and the laser surgeon before and during a treatment course is important since the client shall know the risk that removal can be unsuccessful, with complications and even disfiguring leading to regret at the end.

Diagnostic Tools for Doctors' Evaluation of Tattoo Complications.

Diagnosis of tattoo complications is a multi-facetted field since many clinical entities and disease mechanisms are represented. Infections, allergies, and pigment foreign body reactions with granuloma are the major groups. The clinician needs a structured approach to diagnosis and an armamentarium of standard tests. Diagnosis primarily builds on patient history, objective clinical examination, and punch biopsy, supplemented with microbiology testing, ultrasound scanning, and clinical photography. Evaluation of allergic tattoo reactions and allergy to pigments by patch testing is not applicable and has a falsely negative outcome except for the diagnosis of allergy to metals and preservatives. Simple inspection of raw punch biopsies from chronic tattoo reactions, preferably evaluated with stereo microscopy, provides important information about the density and the local distribution of tattoo pigment in the dermis and changes of micro- anatomical skin structures. Histology may show subtle structural changes, but traditional patterns (lichenoid reaction, pseudolymphoma, granuloma, and pseudoepitheliomatous epidermal hyperplasia) are of little or no help in the diagnosis since the patterns overlap and have no distinct clinical correlates. Histology cannot separate allergic and nonallergic reactions. However, granulomatous reaction and sarcoid granuloma are significant findings since papulonodular reaction of black tattoos and sarcoidosis are strongly associated with each other. 20-MHz ultrasound scanning is important for noninvasive imaging and characterization of inflammatory tattoo reactions and can be used preoperatively as guide to treatment. Electron microscopy can visualize pigment particles in tissues, cells, and tattoo inks. Chemicals of pigment in tissues and in tattoo inks can be analyzed by high-performance liquid chromatography, mass spectroscopy, and Raman spectroscopy.