Tattoo-associated dermatoses: a case report and review of the literature

Immediate and Sustained Effects of Cobalt and Zinc-Containing Pigments on Macrophages

Pigments are among the oldest nanoparticulate products known to mankind, and their use in tattoos is also very old. Nowadays, 25% of American people aged 18 to 50 are tattooed, which poses the question of the delayed effects of tattoos. In this article, we investigated three cobalt [Pigment Violet 14 (purple color)] or cobalt alloy pigments [Pigment Blue 28 (blue color), Pigment Green 14 (green color)], and one zinc pigment [Pigment White 4 (white color)] which constitute a wide range of colors found in tattoos. These pigments contain microparticles and a significant proportion of submicroparticles or nanoparticles (in either aggregate or free form). Because of the key role of macrophages in the scavenging of particulate materials, we tested the effects of cobalt- and zinc-based pigments on the J774A.1 macrophage cell line. In order to detect delayed effects, we compared two exposure schemes: acute exposure for 24 hours and an exposure for 24 hours followed by a 3-day post-exposure recovery period. The conjunction of these two schemes allowed for the investigation of the delayed or sustained effects of pigments. All pigments induced functional effects on macrophages, most of which were pigment-dependent. For example, Pigment Green 19, Pigment Blue 28, and Pigment White 4 showed a delayed alteration of the phagocytic capacity of cells. Moreover, all the pigments tested induced a slight but significant increase in tumor necrosis factor secretion. This effect, however, was transitory. Conversely, only Pigment Blue 28 induced both a short and sustained increase in interleukin 6 secretion. Results showed that in response to bacterial stimuli (LPS), the secretion of tumor necrosis factor and interleukin 6 declined after exposure to pigments followed by a recovery period. For chemoattractant cytokines (MCP-1 or MIP-1α), delayed effects were observed with a secretion decreased in presence of Pigment Blue 28 and Pigment violet 14, both with or without LPS stimuli. The pigments also induced persisting changes in some important macrophage membrane markers such as CD11b, an integrin contributing to cell adhesion and immunological tolerance. In conclusion, the pigments induced functional disorders in macrophages, which, in some cases, persist long after exposure, even at non-toxic doses.

Atypical Intraepidermal Melanocytic Proliferation Masked by a Tattoo: Implications for Tattoo Artists and Public Health Campaigns

Tattoos have become increasingly popular worldwide. While tattoos carry a minimal risk of complications, previous reports have located malignant melanoma hidden within tattoos. We present a case of an atypical intraepidermal melanocytic proliferation masked by a large tattoo in a 39-year-old Caucasian male. Tattooed skin can be difficult to examine, particularly when the tattoos are dark, pigmented, and extensive. We demonstrate that a careful examination of tattooed skin leads to the early detection of atypical melanocytic proliferations. We present an extensive review of literature related to the relationship between tattoos and skin cancer, as well as public health recommendations for tattoo artists and individuals seeking to obtain tattoos. We urge a vigilant examination of tattooed skin and encourage collaboration between dermatologists and tattoo artists in promoting the detection of suspicious lesions prior and following tattooing.

A case of multiple squamous cell carcinomas arising from red tattoo pigment

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.

Patterns of Reactions to Red Pigment Tattoo and Treatment Methods

Tattoos are common and used extensively as either body art or cosmetic make-up; more rarely, they can be traumatic in nature. We have systemically analysed the literature for the patterns of red pigment tattoo reactions and their treatment options. Our search identified 18 articles; there was 1 non-randomised controlled trial, and the rest were small case studies. In total 139 patients were included within the studies. This review systematically analyses the different subsets of red tattoo reactions including lichenoid, dermatitis, granulomatous, pseudolymphomatous and miscellaneous reactions. The current evidence for the treatment for the above is presented. Dermatitis and lichenoid reactions appear to be the most common subtype of red pigment reactions with various treatment methods applied showing laser intervention to have some degree of success.

Adverse reactions after tattooing: review of the literature and comparison to results of a survey

The number of tattooed people has substantially increased in the past years. Surveys in different countries reveal this to be up to 24% of the population. The number of reported adverse reactions after tattooing has also increased including infections, granulomatous and allergic reactions and tumors. However, the case reports do not reflect the frequency of adverse reactions. This review compares the medically documented adverse reactions published in 1991-2011 with the findings of a nation-wide survey that recently revealed the features and health problems associated with tattoos. To compare the data with the survey, the sex of patients was reported and the location and color of tattoos were evaluated. The results show clearly that colored tattoo inks are mainly responsible for adverse skin reactions and that tattoos on the extremities are involved most.

Increased incidence of cutaneous nontuberculous mycobacterial infection, 1980 to 2009: a population-based study

OBJECTIVES

To determine the incidence and clinical characteristics of cutaneous nontuberculous mycobacterial (NTM) infection during the past 30 years and whether the predominant species have changed.

PATIENTS AND METHODS

Using Rochester Epidemiology Project data, we identified Olmsted County, Minnesota, residents with cutaneous NTM infections between January 1, 1980, and December 31, 2009, examining the incidence of infection, patient demographic and clinical features, the mycobacterium species, and therapy.

RESULTS

Forty patients (median age, 47 years; 58% female [23 of 40]) had positive NTM cultures plus 1 or more clinical signs. The overall age- and sex-adjusted incidence of cutaneous NTM infection was 1.3 per 100,000 person-years (95% CI, 0.9-1.7 per 100,000 person-years). The incidence increased with age at diagnosis (P=.003) and was higher in 2000 to 2009 (2.0 per 100,000 person-years; 95% CI, 1.3-2.8 per 100,000 person-years) than in 1980 to 1999 (0.7 per 100,000 person-years; 95% CI, 0.3-1.1 per 100,000 person-years) (P=.002). The distal extremities were the most common sites of infection (27 of 39 patients [69%]). No patient had human immunodeficiency virus infection, but 23% (9 of 39) were immunosuppressed. Of the identifiable causes, traumatic injuries were the most frequent (22 of 29 patients [76%]). The most common species were Mycobacterium marinum (17 of 38 patients [45%]) and Mycobacterium chelonae/Mycobacterium abscessus (12 of 38 patients [32%]). In the past decade (2000-2009), 15 of 24 species (63%) were rapidly growing mycobacteria compared with only 4 of 14 species (29%) earlier (1980-1999) (P=.04).

CONCLUSION

The incidence of cutaneous NTM infection increased nearly 3-fold during the study period. Rapidly growing mycobacteria were predominant during the past decade.

Poorly differentiated squamous cell carcinoma arising in tattooed skin

Introduction. Tattoos have increasingly become accepted by mainstream Western society. As a result, the incidence of tattoo-associated dermatoses is on the rise. The presence of a poorly differentiated squamous cell carcinoma in an old tattooed skin is of interest as it has not been previously documented. Case Presentation. A 79-year-old white homeless man of European descent presented to the dermatology clinic with a painless raised nodule on his left forearm arising in a tattooed area. A biopsy of the lesion revealed a poorly differentiated squamous cell carcinoma infiltrating into a tattoo. The lesion was completely excised and the patient remains disease-free one year later. Conclusion. All previous reports of squamous cell carcinomas arising in tattoos have been well-differentiated low-grade type or keratoacanthoma-type and are considered to be coincidental rather than related to any carcinogenic effect of the tattoo pigments. Tattoo-associated poorly differentiated invasive carcinoma appears to be extremely rare.

Body-modifying concepts and dermatologic problems: tattooing and piercing

Recently, piercing and tattooing have gained increasing popularity worldwide, through all social classes and age groups. Besides pierced ear lobes, piercing of the tongue, nose, nipples, belly button, and even the genitals is quite common. The variety of tattoos range from temporary henna tattoos to permanent makeup and permanent tattoos, where the pigments are deposed in the dermis. These trends are supplemented by more invasive methods of body modification such as implanting, scarification, or branding. Parallel with the increasing popularity of piercing and tattoos, the knowledge about associated complications rose. Complications depend substantially on the circumstances in which body modifications are applied, the materials used, and the body region concerned. This article gives an overview of the most common complications of body modification methods, which mainly result from shortcomings in the application itself or in hygiene regimens. Consequences may be as severe as life-threatening events or permanent malfunction of different organs.

Particularities in managing melanoma patients with tattoos: case report and review of the literature

Assessing pigmented lesions within or covered by tattoos is difficult, both at a clinical and dermatoscopic level. Patients with tattoos may provide a challenge in the early recognition and follow-up of melanoma.

Winnie the Pooh and psoriasis too: an isomorphic response of guttate psoriasis in a tattoo

Since Koebner's first observance of the isomorphic response of psoriasis in a tattoo in 1872, a paucity of written reports has appeared in the literature describing this phenomenon, although it appears to be common knowledge among dermatologists. We report a strep-induced guttate psoriasis isomorphic response in a Winnie the Pooh tattoo in a 19-year-old.

Tattoos: surgical removal

Surgical treatment of tattoos remains a useful tool for complete removal despite the availability of laser and other nonsurgical techniques. The procedures are in accordance with standard dermatosurgery used in aesthetic and oncologic therapies. Healing by primary intention or healing by secondary intention has its own indications. Skin defects can be closed by flaps, grafts, tissue extension, or tissue expansion.

[Certificate: "Occupational Dermatology (ABD)". New curriculum 2006 of the CME-seminars of the Task Force of Occupational and Environmental Dermatology]

The certification of experts is an important component in the overall concept of quality management in occupational dermatology. With the certificate "Occupational Dermatology (ABD)" the Task Force on Occupational and Environmental Dermatology (ABD) has developed a comprehensive CME concept in the field of medico-legal evaluations. The ABD seminars meet the current requirements of the statutory accident insurances and social welfare courts. The new CME seminar curriculum 2006 of the ABD takes into account the recent pioneering achievements in occupational dermatology, e.g. the Bamberg leaflet, the optimized dermatologic report and other prevention/early intervention measures. The ABD seminars (total of 21 hrs) are subdivided into 3 consecutive modules: basic, advanced and special seminar (7 hrs each). The seminars are interactive, based on practice-oriented discussions with experts from different disciplines (occupational dermatology, social law). The seminars should be attended in chronological order; there are no time limits during which they must be completed. Prerequisite for the certification is a specialist's degree in dermatology. To maintain the certificate it is expected to attend one of the newly-created ABD "quality management workshops" (7 hrs) within 5-year-intervals; these focus on interdisciplinary case discussions of the current legal regulations and recent social welfare court decisions. More than 400 dermatologists have already been certified by the ABD.

In vivo imaging of intradermal tattoos by confocal scanning laser microscopy

BACKGROUND/AIMS

In vivo confocal laser scanning microscopy (CLSM) is a new method for high-resolution imaging of intact skin in situ. Horizontal mapping of the outer skin is provided (magnification x 1000).

OBJECTIVES

Tattooing is popular all over the world; however, tattooed skin has not been studied in using CLSM.

RESULTS

Tattoos in two volunteers were studied using the Vivascope1500 of Lucid Inc. Subepidermal massive deposits of dense, clustered pigment granules up to about 3 mum in size corresponding to black tattoos, and more scarce and diffuse deposits, corresponding to red, blue and green tattoos, were observed. Diffuse pigment granules tended to accumulate in the outer dermis underneath the level of the basement membrane zone.

CONCLUSIONS

Dermal pigments from tattoos can be imaged in vivo using CLSM. This application of CLSM has an important future potential for pre-evaluation of tattoos before laser removal, predicting good or poor outcome of laser removal.

METABOLISM OF PIGMENT YELLOW 74 BY RAT AND HUMAN MICROSOMAL PROTEINS

Pigment Yellow 74 (PY74) is a monoazo pigment that is used in yellow tattoo inks. The metabolism of PY74 was investigated using rat liver and human liver microsomes and expressed human cytochromes P450 (P450s). Two phase I metabolites were isolated and characterized by mass spectrometry and NMR techniques. One metabolite (PY74-M1) was a ring hydroxylation product of PY74, 2-((2-methoxy-4-nitrophenyl)azo)-N-(2-methoxy-4-hydroxyphenyl)-3-oxobutanamide. The second metabolite (PY74-M2) was identified as 2-((2-hydroxy-4-nitrophenyl)azo)-N-(2-methoxy-4-hydroxyphenyl)-3-oxobutanamide, which is the O-demethylation product of PY74-M1. These metabolites were formed by in vitro incubations of PY74 with 3-methylcholanthrene-induced rat liver microsomes and to a much lesser extent by liver microsomes from untreated or phenobarbital-induced rats. The role for CYP1A in the metabolism of PY74 was confirmed using expressed human P450s. The catalytic ability of the P450s for metabolism of PY74 was CYP 1A2 > CYP 1A1 > CYP 3A4 approximately CYP 1B1 (no activity with CYP 2B6, 2C9, 2D6 or 2E1). The metabolism of PY74-M1 to PY74-M2 was catalyzed only by CYP 1A2 and CYP 1A1 (no activity from CYP 1B1, 2B6, 2C9, 2D6, 2E1, or 3A4). These results demonstrate that the tattoo pigment PY74 is metabolized in vitro by P450 to metabolites that should be available for phase II metabolism and excretion.

A tattooed butterfly as a vector of atypical Mycobacteria

We report the first case of cutaneous inoculation of atypical Mycobacteria secondary to tattooing. The diagnosis of atypical Mycobacteria infection of the skin was confirmed on the basis of the clinical and histologic appearance, the detection of acid-fast bacilli on Ziehl-Neelsen stain, and positive polymerase chain reaction. The medical complications of tattooing, which are manifold, are briefly summarized. This case emphasizes the need for federal regulation of tattooing, which is an invasive procedures associated with infectious and noninfectious complications.