Lichenoid delayed hypersensitivity reactions in tattoos

Growing trend of tattooing and its complications in Nigeria

Tattoo, a Polynesian word meaning 'to mark', is a form of body modification done by inserting indelible ink into the dermis to change its pigmentation. Tattoos are done for social, cultural, and religious purposes. It has been in existence since the 18th century and was associated with sailors, lower class individuals, and criminals. However, since the late 20th century, tattooing has undergone a redefinition and shifted to an acceptable form of expression all over the world, including Nigeria, cutting across almost all age groups and socioeconomic class. This review is aimed at highlighting the indication, complications arising from the procedure as well as removal, and how to manage them. The dermatological complications associated with tattoos can occur either during inking or attempts at removal. Most times, tattoos are obtained through unsafe means by unauthorized personnel, and this is associated with numerous health risks. Of particular importance to the dermatologists are the hypersensitivity reactions, granulomatous skin disease, and formation of both keloid and hypertrophic scars. Treatment options vary and include use of silicone gel and intralesional steroids for hypertrophic and keloid scars, topical medication for hyperpigmentation, and use of LASER for tattoo removal. In conclusion, the trend of tattooing has become a widely accepted form of social expression all over the world and is gradually gaining ground in Nigeria. Patients frequently present to the dermatologists and physicians for solutions to the complications. It is important to proffer solutions and educate patients on the various health risks associated with tattooing.

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.

Perforating granulomatous dermatitis reaction to exogenous tattoo pigment: a case report and review of the literature

: The majority of cutaneous hypersensitivity reactions to exogenous tattoo pigments can be histologically classified as lichenoid or granulomatous. The etiology is still uncertain but is generally accepted to be a delayed-type hypersensitivity reaction to either the pigment itself or its carrier solution. In this report, we review the literature concerning adverse reactions to tattoos. In addition, we describe the second case of a localized granulomatous dermatitis to the red dye within a tattoo that histologically resembled granuloma annulare. This is the first reported example of a perforating granuloma annulare-like reaction.

Eruptive squamous cell carcinomas, keratoacanthoma type, arising in a multicolor tattoo

Permanent tattoos are formed through the injection of ink solids through the epidermis into the dermis and can cause multiple adverse reactions. We report a 38-year-old man who presented to our Dermatologic Surgery Unit with a diagnosis of a superficially invasive squamous cell carcinoma (SCC), keratoacanthoma (KA) type, of the left forearm in a 1-month-old tattoo. Since his initial biopsy, he developed four more similar lesions on his left forearm within his tattoo. On physical examination, the patient had a large, multicolor tattoo on his left forearm, a well-healed surgical biopsy site and four erythematous hyperkeratotic papules within differently pigmented areas of the patient's tattoo. Histopathological examination showed KA and tattoo pigment. Based on the eruptive nature of these lesions, their clinical presentation and the histopathological changes, we report this as the first case of eruptive KA arising in a multicolor tattoo.

Pseudoepitheliomatous hyperplasia ? an unusual reaction following tattoo: report of a case and review of the literature

A 59-year-old woman presented with an itchy and uncomfortable raised lesion at a tattoo site (Fig. 1) on the lateral aspect of the left leg, just above the ankle. The tattoo had been placed 2 years before her presentation and the tattoo site was sun exposed. Immediately after she had the tattoo, she noticed redness of the skin. After a week, a pruritic and red scaly nodule developed that continued to gradually enlarge until her presentation. The patient had tried topical vitamin A and D ointment with no relief. The patient also had tattoos on the arms without any noticeable skin changes. The patient reported that the tattoo procedure on her leg was more painful than that on her arms, and was performed by a different (and perhaps inexperienced) tattoo artist. The original tattoo contained red, green, and yellow pigments. A diagnosis of tattoo granuloma was considered; squamous cell carcinoma and fungal infection were included in the differential diagnosis. A punch biopsy was performed, followed by complete surgical excision of the lesion with a split-thickness skin graft from the right thigh. The skin excision specimen showed a 3 x 2.5-cm granular and pitted pink lesion with well-demarcated, somewhat irregular borders. The lesion was raised 0.5 cm above the skin surface. The lesion was present in the center of the original tattoo. Portions of the original tattoo with green and blue-green pigmentation were visible on either side of the lesion. No satellite lesions were identified. Microscopically, the raised lesion demonstrated striking pseudoepitheliomatous hyperplasia, with irregular acanthosis of the epidermis and follicular infundibula, hyperkeratosis, and parakeratosis (Fig. 2). Follicular plugging was present with keratin-filled cystic spaces. There was a brisk mononuclear inflammatory infiltrate in the dermis, composed primarily of lymphocytes, with admixed plasma cells and histiocytes. Giant cells were occasionally identified. Dermal pigment deposition was noted both within the lesion and in the surrounding skin, corresponding to the original tattoo. Variable dermal fibrosis was noted, with thick collagen bundles in some areas. There was no evidence of epidermal keratinocytic atypia, dyskeratosis, or increased suprabasal mitotic activity. Special stains (periodic acid-Schiff and acid-fast) for microorganisms were negative.

Red tattoo reactions

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.

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

BACKGROUND

Tattoos are increasingly popular in today's society, especially with the advent of laser tattoo removal. As a result, observed reactions within tattoos are likely to become more abundant. Three main classes of tattoo-associated dermopathies can be distinguished in the English literature: allergic/granulomatous/lichenoid, inoculation/infection, and coincidental lesions. Injury to the dermis, such as during placement of a tattoo, can also flare a Koebner response in patients with active susceptible disease.

OBJECTIVE

This case report and review of the English literature provides a quick reference to tattoo reactions, techniques available for removal of tattoos, and disorders other than tattoos known to exhibit the Koebner response.

METHODS

The English literature was reviewed via MEDLINE citations from 1966 to December 2001 to delineate articles involving tattoo reactions and Koebner reactions significant to dermatology.

CONCLUSION

Numerous conditions have been documented in association with tattoos and the process of tattoo application. Awareness and identification of dermatoses associated with tattoos, tattoo removal options, and conditions associated with the Koebner response are important to both the dermatologist and dermatologic surgeon.

Morphea-like tattoo reaction

Tattoo reactions are histologically diverse. In general, dermal changes predominate, although epidermal changes such as acanthosis or spongiosis can also be seen. The chronic inflammatory cell infiltrate can be nodular, lichenoid, or granulomatous. Occasionally, the dermal infiltrate may be so dense as to suggest a diagnosis of cutaneous lymphoma. We report an unusual tattoo reaction that mimicked morphea histologically.

Three cases of linear lichen planus caused by dental metal compounds

Three cases of linear lichen planus on the lower extremities unaccompanied by mucous lesions are described. Dental metal compounds were thought to be the precipitating factor in all cases. Skin lesions did not respond to topical steroid ointment or antihistamines. Two cases showed a positive patch test reaction to gold (HAuCl4) and a positive lymphocyte stimulation test to gold compound (Gold sodium thiomalate). One case showed a positive patch test reaction to mercury (HgCl2), but a negative lymphocyte stimulation test. Suspected metal compounds were demonstrated in their dental materials. Removal of gold materials in one case gradually improved the lesions within 6 months with a transient erythematous swelling of the face shortly after removal of the metal. Both of these cases responded to oral disodium chromoglycate therapy. These results suggest that metal compound specific T cells might be responsible for the development of linear lichen planus.

Oral lichenoid lesions, mercury hypersensitivity and combined hypersensitivity to mercury and other metals: histologically-proven reproduction of the reaction by patch testing with metal salts

We report 11 patients seen between 1991 and 1994 with oral lichenoid lesions (OLL). In 10 cases, there was contact with dental amalgam fillings, and in patient no. 10 with both amalgam restorations and a gold crown. The last patient had, in addition to her OLL, lichen planus of the skin and genital mucosa. In 5 cases, combined sensitization to mercury and other metal salts, particularly gold sodium thiosulfate (GST) and palladium chloride (PDC), was observed. In 10 patients, the lesions considerably improved or totally cleared within 1 to 9 months of replacement of restoration materials. Histological examination of biopsies from the test sites of amalgam, mercuric chloride, GST and PDC, taken 10 or 17 days after application of patch tests, showed lichenoid changes in 7 patients with at least 1 of the allergens. As at least 2 patients had inflammatory lesions of the oral mucosa related to both amalgam and gold restorations, combined sensitization to inorganic and organic mercury derivatives, GST and, in 1 case, PDC, a "dental restoration metal intolerance syndrome" is proposed.

Red tattoo reactions: X-ray microanalysis and patch-test studies

Eighteen patients who developed cutaneous reactions to red tattoos were studied to identify the chemicals responsible for the reactions to modern red tattoo pigments. Biopsies from the tattoos were examined histologically and the chemical composition of the red pigments was analysed by X-ray microanalysis. A variety of metallic elements including aluminium, iron, calcium, titanium, silicon, mercury and cadmium were detected. Patch tests were performed to the relevant chemicals in nine cases, and only one patient reacted to mercury. This study demonstrates that although reactions to mercury still occur, other red dyes containing a variety of inorganic pigments may provoke a cutaneous inflammatory response.

No evidence of hypersensitivity to dental restorative metals in oral lichen planus

Twelve patients with oral lichen planus (OLP) suspected of dental restorative metal allergy were examined. All patients were patch tested with several metals including six different mercury compounds. One (8%) patient showed a positive patch test to two mercury compounds whereas no mercury allergy was found in a reference group of 17 patients suspected of dental restorative material allergy but without OLP lesions. The mercury allergic OLP patient was further tested on palatal mucosa but no reactions developed. Moreover, the energy dispersive X-ray microanalysis failed to show any contaminating metals in his OLP lesion. Mucosal biopsies were taken in close contact with amalgam fillings from nine OLP patients but these disclosed no evidence of lichenoid or dysplastic alterations. In OLP lesions, the immunofluorescence findings showed fibrinogen deposition, altered basement membrane and elastic fiber staining and intense Ulex europeaus I lectin fluorescence through all epithelial cell layers. Therefore, the present patch tests did not reveal increased frequency of mercury or other metal allergy in OLP patients and the mucosal biopsies failed to show any histologic or immunofluorescence alterations deviating from idiopathic OLP lesions.

Oral lichen planus: hypersensitivity to dental restoration material

67 patients with oral lichen planus of the atrophic-erosive or reticular plaque type were examined. Dental amalgam in contact with mucosal lesions was present in 64 patients, and gold fillings in 33. Patch testing with a standard procedure was performed with components of dental fillings. 11 patients (16%) reacted to at least one of the mercury compounds compared to 8% in a reference group. Most positive reactions were caused by elemental mercury and ammoniated mercury. No patient reacted to gold or copper. Readings at days 10-14 did not increase the number of responders. 13 patients were patch tested with palladium; all were negative. It is not clear whether in the mercury-positive patients allergy to dental amalgam is a causative or aggravating factor, or merely on epiphenomenon.

Pseudolymphomatous reaction to tattoos. Report of three cases

Three cases with pseudolymphomatous hypersensitivity reaction to tattoo pigment are described. One of the cases showed histologic features of Spiegler-Fendt pseudolymphoma. Awareness of this type of reaction to tattoo pigment can help prevent erroneous diagnosis of lymphoma. Several published reports are cited in which pseudolymphomatous reaction to tattoo pigment was erroneously diagnosed as lymphoma.