Treatment of reaction to red tattoo ink with intralesional triamcinolone.

Dear Editor,

Body tattoos are becoming increasingly popular. A national survey revealed that approximately a quarter of American adults aged between 18 and 50 years had tattoos.[1] Dermatologists worldwide are requested for tattoo removal, counseling, and treatment for tattoo reactions. No consistently effective treatment for tattoo reactions has been reported to date.[2] If the tattoo reaction area is small, surgical excision, 10,600-nm CO2 laser, cryosurgery, or radiofrequency ablation may be performed. However, in cases of multiple tattoos or large surface area with reaction, or ablation over the lower extremities, the risk of suboptimal scar development is high. A 35-year-old woman presented with extremely pruritic nodules on the right leg, ankle, foot, and posterior trunk over tattoos for more than nine months (. She was an otherwise healthy patient with Fitzpatrick skin type III, without peripheral lymphadenopathy. She presented normal blood count and negative serologic tests for HIV and hepatitis B and C. She had been prescribed hydroxyzine 25mg three times a day, topical clobetasol ointment .05% three times a day for a month, and fludroxycortide 4mcg/cm2 tape, without resolution of symptoms or involution of the nodules.

A deep skin punch biopsy was taken from the most pruritic site of the right ankle. Pathology review showed marked epidermal hyperplasia with dermal fibrosis and chronic, lymphoplasmacytic inflammatory infiltrate around ink deposits. Keloid, lymphomatoid reaction, and atypical mycobacterial and fungal infections were ruled out (Figure ).

Figure 2

Tattoo hypersensitivity reaction. Photomicrographs. A. Scanning magnification reveals a marked epidermal hyperplasia, papillomatosis, and hyperkeratosis, with intense dermal chronic inflammatory infiltrate, black and dark red pigmented deposits and moderate fibrosis (Hematoxylin & eosin; original magnification X40). B. Higher magnification shows details of the pigmented deposits, lymphoplasmacytic infiltrate, and fibrosis (Hematoxylin & eosin; original magnification X200). The arrows point out detected areas of dark red ink deposition

Despite the use of topical steroids for weeks, as seen in Figure , color could barely be seen through the thick acanthosis. Therefore, frequency-doubled Q-switched 532 nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser would not penetrate deep enough through the hyperkeratosis to produce the desired effect on the red ink.

Figure 1

Tattoo hypersensitivity reaction. Exuberant verrucous nodules caused by red tattoo ink on the right ankle. These nodules were extremely pruritic revealing excoriations and moderate lichenification of the surrounding skin

The chosen therapy was intralesional triamcinolone acetate injections 40 mg/ml (maximum volume of 1ml per monthly session). Three treatment sessions were required for total resolution. The injected lesions showed a rapid involution of the nodules and symptoms, and the vivid red color reappeared after the first treatment session (.

Tattoo hypersensitivity reaction. One-month follow-up. Improvement of pruritus and involution of verrucous nodules on the ankle. Collateral effects: mild atrophy and telangiectasia was evident on adjacent areas after improvement of pruritus and lichenification

Red pigments are the most common cause of delayed hypersensitivity reactions in tattoos.[2-4] Our patient has been in remission for five years. Although intralesional steroid therapy is a simple technique, collateral effects are to be expected at a high dosage, such as epidermal and dermal atrophy, and telangiectasia. Cases of linear atrophy have already been described suggesting lymphatic spread of injected triamcinolone.[5] Since this treatment modality is still investigational, future studies are needed to establish its efficacy, with different concentrations, and relapse rates. Although this case required no further treatments, alternative treatments could be possible - but not preserving the cosmetic integrity of the tattoo - such as excision, cryosurgery, electrosurgery, Q-switched 532nm laser, or laser ablation. Tattoo reactions may be a contraindication for laser treatment as the treatment can boost systemic hypersensitivity.