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Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019
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Image courtesy of Bassi A, Campolmi P, Cannarozzo G, et al. Biomed Res Int. 2014;2014:354608. PMID: 25147796. PMCID: PMC4132403. [Open access.]
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
The above image shows (left) a pseudolymphomatous reaction in the red-pigmented region of a tattoo and (right) lesion resolution following four treatments with a Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser.
Although the complications associated with tattooing and tattoo removal are often mild and self-limited, significant adverse events are possible with both.[1-3] The introduction of foreign pigments into the skin can result in inflammatory reactions to the pigments, the transmission of infectious diseases, and the localization of skin disease within tattoos secondary to trauma. Moreover, the removal of tattoos, typically performed with solid-state lasers that emit ultrashort pulses in the nanosecond or picosecond range, is also not without its host of potential complications. These include burns, blisters, infections, irregular pigmentation, and, rarely, scarring.[1]
Image from Science Source.
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
This light micrograph of a cross section of human skin shows a layer of tattoo ink (200× magnification on a 35-mm sensor).
A tattoo is made when permanent ink is inserted into the dermis (lower layer of the skin) with a needle. Exogenous tattoo pigment granules measure 2-400 nm in diameter and can be located extracellularly or, following ingestion by dermal fibroblasts, macrophages, or mast cells, intracellularly.[4]
Image courtesy of Chakir K, Hassam B. Pan Afr Med J. 2013;15:148. PMID: 24396554. [Open access.]
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
This image shows a bullous (or blistering) allergic reaction to a henna tattoo.
An allergic hypersensitivity to tattoo pigments is a potential adverse event that may manifest itself over days to months in several ways, including contact dermatitis or photoallergic dermatitis.
Image courtesy of Bassi A, Campolmi P, Cannarozzo G, et al. Biomed Res Int. 2014;2014:354608. PMID: 25147796. PMCID: PMC4132403. [Open access.]
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
Shown are (a) a pseudoepitheliomatous hyperplastic reaction on a red tattoo and (b) inflammation in the dermis (arrow).
Allergic hypersensitivity reactions to tattoos occur when the immune system is hypersensitized to the tattoo pigment due to prior exposure. Red pigments are the most common cause of such reactions,[5] but any tattoo pigment may elicit them. For example, allergic reactions can be a response to a variety of metallic salts that may be employed to produce different colorations, such as cadmium (yellow), manganese (purple), cobalt (blue), and chromium (green).[6]
Image from Science Source.
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
This close-up image of a rash on the wrist of a 39-year-old woman shows a lichenoid dermatitis at the site of a tattoo.
Allergic reactions can be treated with topical and intralesional corticosteroids or antihistamines to reduce inflammation and itching. Surgical excision can be considered for the treatment of inflamed tattoos. Laser therapy may lead to resolution after multiple treatments; however, patients should be monitored in-office for at least 30 minutes following laser treatment, given the potential for induction of a systemic allergic reaction.
Image courtesy of Bittencourt Mde J, Miranda MF, Parijós AM, Mesquita LB, Fonseca DM, Jambo DA. An Bras Dermatol. 2013;88(4):614-6. PMID: 24068136. [Open access.]
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
A healthy 24-year-old male presented with a pink nodule within a tattoo on his right lower leg (shown). The eruption began 2 months after the addition of black ink to a previously existing tattoo. Clinical examination revealed an erythematous, freely movable nodule overlying an area of black pigment on the inferior aspect of the tattoo, with slight tenderness to palpation. The lesion was consistent with a nodular hypersensitivity reaction.
Images courtesy of Lawrence Charles Parish, MD (Parish Dermatology, Philadelphia, PA).
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
These images show contact dermatitis caused by allergic hypersensitivity to red tattoo pigments.[5] Mercury sulfide (cinnabar) is the most likely culprit in these cases. Allergic reactions to red tattoos are more common when mercury sulfide is used for pigmentation, but other varieties of pigments can also cause such hypersensitivity reactions.
Patch testing may be positive for mercury chloride, but this test is not reliable for cinnabar. Alternative red dyes have been developed because of the problems associated with mercury-containing red tattoo pigments; however, red tattoo reactions, such as granulomatous and nodular tattoo skin reactions, continue to be reported.
Image courtesy of W. Justin McCrary, MD (Dermatology Associates, Greenville, SC).
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
This image shows another example of an erythematous allergic hypersensitivity reaction to a tattoo, in this case on the left lateral arm.
Image courtesy of Medscape | National Institutes of Health (NIH).
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
This image also shows an erythematous allergic hypersensitivity reaction to a tattoo, here on the lower back.
Image courtesy of Fioramonti P, Fino P, Ruggieri M, Scuderi N, Onesti MG. Case Rep Med. 2012;2012:253492. PMID: 23251168. [Open access.]
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
Two weeks after getting a tattoo on his arm, a 25-year-old man presented with locoregional pain, itching, warmth, and four ulcerative lesions (shown in the square). The plaques were 0.5-1.0 cm in diameter, with purulent discharge and abundant fibrin. A bacterial culture of the discharge was positive for Staphylococcus aureus and Streptococcus pyogenes.
Image courtesy of Ruiz-Villaverde R, Sánchez-Cano D. Pan Afr Med J. 2013 Oct 11;16:49. PMID: 24648862. [Open access.]
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
This image shows the abdomen of a 23-year old patient who presented with pearled papules over a tattoo. The patient was diagnosed with molluscum contagiosum, which may have been transmitted through unclean instruments or contaminated ink.
Although current standards for hygiene and infection control in tattooing have made infections unusual, bacteria may still be introduced percutaneously due to breach of the epidermal barrier. Transmission of tuberculosis, syphilis, leprosy, hepatitis, and human immunodeficiency virus (HIV) from tattooing has also been reported.[7]
Image courtesy of Kay MK, Perti TR, Duchin JS. Emerg Infect Dis. 2011 Sep; 17(9): 1734–1736. PMID: 21888807. [Open access.]
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
A healthy 44 year old developed a painless pustular rash (shown) at the site of a new forearm tattoo three days after the tattoo was completed. The patient was diagnosed with Mycobacterium haemophilum infection following positive acid-fast bacilli results from Middlebrook 7H10 and chocolate agar plates incubated at 30°C.
Images from Science Photo Library (top left, bottom right) and Alamy (top right, bottom left).
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
Q-switched nanosecond and picosecond lasers are the mainstays of tattoo removal, allowing for thermal damage to exogenous pigment particles with minimal injury to the surrounding skin.[7,8] Selection of an appropriate laser wavelength is based entirely on the color(s) of the tattoo pigment(s) being targeted, with the wavelength chosen by means of "complementary matching." Green tattoo pigment is most effectively removed by a wavelength of 694 or 755 nm, red tattoo pigment is best removed with a 532-nm wavelength, and blue and black pigments are removed with a 694-, 755-, or 1064-nm wavelength.[9] Yellow and orange tattoo pigments are more difficult to remove but can often be treated effectively with a 532-nm wavelength.
Image from Alamy.
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
The clinical endpoint of laser tattoo removal is immediate tissue whitening (without pinpoint bleeding) due to a sudden buildup of water vapor around the targeted pigment particles. The physical breakup of these exogenous particles allows macrophages and the lymphatic system to clear them.[10]
Images courtesy of Douglas C. Wu, MD, PhD; Ana M. Liolios, MD; and Mitchel P. Goldman, MD (Cosmetic Laser Dermatology, San Diego, CA).
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
Blistering is a transient adverse event associated with laser tattoo treatment. It is more common with the first few treatment sessions and is due to subepidermal bullae formation secondary to rapid accumulation of inflammatory exudate. This multicolored tattoo on the lateral arm of a Caucasian male (left) was treated with a Q-switched picosecond alexandrite (755-nm) laser. Extensive blistering developed after the first treatment session and lasted approximately 5 days (middle). Blistering typically resolves within several days of laser therapy without scarring or other sequelae (right). The use of ablative fractionated resurfacing immediately following tattoo laser treatment dramatically decreases the incidence of bullae formation.[11]
Image courtesy of Daniel P. Friedmann, MD.
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
Superficial skin infections are uncommon following Q-switched laser therapy. Two weeks following the first Q-switched picosecond alexandrite (755-nm and 532-nm) laser treatment of her multicolored foot tattoo, this Caucasian patient returned with diffuse, superficial erythema; crusting; and oozing, associated with occasional pruritus. She had been applying a physician-recommended, bland healing ointment, with progressive worsening of signs and symptoms. Wound culture revealed the presence of methicillin-resistant S aureus (MRSA), suggesting a diagnosis of impetigo. Doxycycline 100 mg taken orally twice daily for 10 days led to complete resolution.
Image courtesy of Daniel P. Friedmann, MD.
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
Retreatment of the prior patient with the same Q-switched picosecond alexandrite (755-nm and 532-nm) laser led to erythematous, raised, pruritic plaques localized to the red tattoo areas only. Findings were consistent with an allergic contact hypersensitivity to red tattoo pigment, elicited by laser treatment. The patient denied having had any similar signs and symptoms following tattooing. Interestingly, an untreated red tattoo on the medial ankle of the same foot developed erythema and pruritus concurrently.
Image courtesy of Daniel P. Friedmann, MD.
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
A tattoo before (left) and after (right) 20 sessions of Q-switched picosecond alexandrite (755-nm) laser therapy for black tattoo ink, with tattoo "ghosting" due to residual dermal pigment.
Image from Science Source.
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
This image shows hypertrophic scarring and dyspigmentation on the arm of an adult female following laser treatment of a tattoo.
Q-switched nanosecond and picosecond lasers rarely result in scarring. However, there can be significant textural and pigmentary changes after multiple treatments when these devices are used at inappropriately high fluences.
Images courtesy of Daniel P. Friedmann, MD.
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
The evolution of Q-switched nanosecond and picosecond lasers has allowed safer pigment eradication, including less scarring and/or pigmentary changes. However, adverse reactions can still occur,[1] particularly in dark-skinned individuals (in whom hypopigmentation and hyperpigmentation are the most common side effects).
A 44-year-old Hispanic female with a multicolored tattoo on her right lower abdomen (bottom left) was treated with a Q-switched picosecond alexandrite (755-nm) laser. The patient reported erythema, moderate blistering, and diffuse dyspigmentation after two sessions 1 month apart (top right). However, hypopigmented areas had significantly improved by 10-month follow-up (bottom right), without the need for additional treatment.
Images courtesy of Daniel P. Friedmann, MD.
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
A 40-year-old Caucasian female was treated with a Q-switched picosecond alexandrite (755-nm and 532-nm) laser for a tattoo on the leg with yellow, red, and black pigment. The patient reported up to 1 week of mild urticarial reactions and dermatographism following each treatment session (left), but these resolved with cetirizine 10 mg taken orally twice daily and diphenhydramine 25 mg taken orally at bedtime as needed. Her tattoo is shown before treatment (top right) and after four treatment sessions (bottom right).
Image courtesy of Daniel P. Friedmann, MD.
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
A 62-year-old Caucasian woman requested correction of her eyebrow tattoo. The tail of the tattoo was treated with a Q-switched picosecond alexandrite (755-nm) laser. Darkening of treated areas was noticed immediately posttreatment. This was most likely due to the laser-mediated reduction of ferric oxide (Fe2O3, rust colored) to ferrous oxide (FeO, black colored). Repeat monthly laser treatments of the same area led to resolution of the problem.
Image from Science Photo Library.
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
Surgical excision and skin grafting can be performed to remove tattoos, particularly in patients with allergic hypersensitivity to their tattoos. These procedures were more commonly performed before laser tattoo removal became the standard of care. This close-up image shows a skin graft site on a man's arm midway through his treatment.
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
A 26-year-old man applied an unknown liquid product for 10 minutes in a botched attempt to remove tattoos on the dorsum of both hands. After a few hours, he sought medical attention because of persistent burning pain and discomfort. The patient required tangential excision and split-skin grafting on both hands because of the extent of the chemical burns. The images shown are of the left hand 48 hours after the chemical burn (left) and following tangential excision (right).
Images courtesy of Daniel P. Friedmann, MD.
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
A Hispanic woman had a tattoo on her left deltoid treated by an inexperienced practitioner with fully ablative CO2 laser resurfacing, which led to significant scarring. The patient presented 1 year posttreatment with erythematous, linear keloidal plaques overlying her tattoo (left). Over a 2-year period, she was treated with numerous sessions of Q-switched picosecond alexandrite (755-nm) laser therapy to clear remaining tattoo pigment and with combination intralesional triamcinolone (10 mg/mL)/5-fluorouracil (50 mg/mL). In addition, conservative fractionated ablative CO2 laser treatments were administered to improve scar appearance (right).
Image courtesy of Daniel P. Friedmann, MD.
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
A 19-year-old male presented with scarring of his right shoulder as a result of at-home treatment with an intense–pulsed-light device marketed online for tattoo removal.[12] The patient reported erythema, blistering, and erosion to ulceration after each self-treatment, leading to progressive scarring after several months of every-other-week therapy. On examination, the patient had a large erythematous keloid containing a healing ulcer.
Images courtesy of Daniel P. Friedmann, MD.
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD | October 10, 2019 | Contributor Information
A 42-year-old Hispanic man had scalp micropigmentation tattooing. Although a black tattoo ink was employed for the procedure, the tattoo developed a Tyndall-like bluish tinge over a few-day period (left). One session with a Q-switched picosecond alexandrite (755-nm) laser (5.7-mm spot size, 0.78 J/cm2) led to complete resolution of this pigment change (right).
Mole or Melanoma? Test Yourself With These Suspicious Lesions
Melanoma accounts for fewer than 5% of skin cancer cases but most skin cancer-related deaths. Early detection is the best means of reducing mortality. Can you correctly diagnose these skin lesions?Slideshows, September 2019
Over the course of the past three decades, the indications for their use and the number of different lasers available to treating physicians have increased dramatically. Combined with widespread media attention fueling a strong public focus on youth and beauty, the volume of laser procedures performed has increased steadily and, with this, so has the number of resulting complications observed from their use.Diseases/Conditions, February 2019
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Contributor Information
Authors
Terrence Keaney, MD, FAAD
Founder and Director, SkinDC
Arlington, VA
Assistant Clinical Faculty of Dermatology
George Washington University
Washington, DC
Disclosure: Terrence Keaney, MD, FAAD, has disclosed no relevant financial relationships.
Daniel P. Friedmann, MD, FAAD
Associate
Westlake Dermatology and Cosmetic Surgery
Clinical Research Director
Westlake Dermatology Clinical Research Center
Austin, TX
Disclosure: Daniel P. Friedmann, MD, FAAD, has disclosed no relevant financial relationships.
Vineet Mishra, MD, FAAD
Division of Mohs Surgery, Dermatology & Vascular Surgery
Scripps Clinic
Adjunct Associate Professor of Dermatology
University of California, San Diego
San Diego, CA
Disclosure: Vineet Mishra, MD, FAAD, has disclosed no relevant financial relationships.
Reviewer
Brett Sloan, MD, FAAD
Associate Professor of Dermatology
University of Connecticut School of Medicine
Residency Site Director
Connecticut Veterans Affairs Healthcare System
Assistant Clinical Professor
Yale University School of Medicine
Editor-in-Chief, Journal of the American Academy of Dermatology Case Reports
Disclosure: Brett Sloan, MD, FAAD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, adviser, consultant, or trustee for: Journal of the American Academy of Dermatology; UpToDate; Medical Review Institute of America.
Editor
Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, NY
Disclosure: Olivia Wong, DO, has disclosed no relevant financial relationships.
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References
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Bassi A, Campolmi P, Cannarozzo G, et al. Tattoo-associated skin reaction: the importance of an early diagnosis and proper treatment. Biomed Res Int. 2014;2014:354608. PMID: 25147796 [Full text].
Forbat E, Al-Niaimi F. Patterns of reactions to red pigment tattoo and treatment methods. Dermatol Ther (Heidelb). 2016 Mar;6(1):13-23. PMID: 26972808 [Full text].
Schwartz RA, Mathias CG, Miller CH, et al. Granulomatous reaction to purple tattoo pigment. Contact Dermatitis. 1987 Apr;16(4):198-202. PMID: 3595119
Rodriguez-Blanco I, Fernandez LC, Suarez-Penaranda JM, Perez del Molino ML, Esteban J, Almagro M. Mycobacterium chelonae infection associated with tattoos. Acta Derm Venereol. 2011 Jan;91(1):61-2. PMID: 21264454
Wollina U, De Cuyper C. Tattoo removal. In: Maibach HI, Gorouhi F, eds. Evidence Based Dermatology. Shelton, CT: People's Medical Publishing House-USA; 2011: chapter 40.
Au S, Liolios AM, Goldman MP. Analysis of incidence of bulla formation after tattoo treatment using the combination of the picosecond Alexandrite laser and fractionated CO2 ablation. Dermatol Surg. 2015 Feb;41(2):242-5. PMID: 25590471
Hammes S, Karsai S, Metelmann HR, et al. Treatment errors resulting from use of lasers and IPL by medical laypersons: results of a nationwide survey. J Dtsch Dermatol Ges. 2013 Feb;11(2):149-56. PMID: 23194381
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