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A Case of a Generalized Lichenoid Tattoo Reaction

Stephanie K. Jacks, MD; Matthew J. Zirwas, MD; Joy L. Mosser, MD
Division of Dermatology, The Ohio State University, Columbus, Ohio; bDivision of Dermatology, Nationwide Children’s Hospital, Columbus, Ohio

Abstract
Cutaneous reactions to tattoos have been increasing in conjunction with the rise in popularity of tattoos. While localized lichenoid reactions to tattoo inks are fairly common, generalized lichenoid reactions are relatively rare. Herein the authors present a case of a generalized lichenoid reaction to a tattoo containing only black ink. They also present a brief discussion of tattoo reactions and treatment options.  (J Clin Aesthet Dermatol. 2014;7(8):48–50.)

A 17-year-old boy with no past medical history presented five weeks after obtaining a professional tattoo with black ink on the left arm. Two weeks after the tattoo, he noted the onset of a generalized, pruritic rash. Examination revealed an African-American male teenager with numerous 1 to 4mm, flat-topped, skin-colored to hyperpigmented papules with a fine white scale, concentrated at the site of the tattoo, but also scattered over the trunk, genitals, and all four extremities, including the dorsal hands and feet (Figure 1,
Figure 2, Figure 3). The oral mucosa was spared. A skin biopsy from the right forearm revealed a lichenoid infiltrate with few eosinophils (Figures 4 and 5). Liver function tests were within normal limits, and hepatitis C antibody was negative. He was treated with triamcinolone acetonide 0.1% cream applied topically twice daily and a two-week oral prednisone taper starting at 40mg. Unfortunately, despite multiple attempts to contact the patient, he was lost to follow-up.

Discussion
Tattoos have been gaining popularity in the adolescent population, a phenomenon that has been well-documented by a recent review article.[1,2] Accompanying the rise in prevalence of tattoos has been an increase in adverse reactions to tattoos, and there has been a push among physicians for greater regulation by the United States Food and Drug Administration (FDA) of tattoo inks.[1,3] The risks of tattooing have been well-characterized, including the contraction of bloodborne diseases, such as hepatitis, localized skin infections, and localized skin reactions.[1] The most common type of localized skin reaction is lichenoid, but other reaction patterns have been reported, including eczematous, granulomatous, or pseudolymphomatous.[4–6] Generalized lichenoid reactions to tattoos are much less common, with only four reported cases in the literature to date.[7–10] Tattoos with red ink have consistently been recognized as the most likely to incite a reaction, despite the evolution in tattoo ink formulations over time. Black ink is much less commonly associated with adverse reactions.[5,9] While the biopsy finding of a lichenoid infiltrate in this case is non-specific, the presence of eosinophils suggests that this case represents a hypersensitivity reaction, rather than another lichenoid eruption, such as lichen planus, which is characterized classically by the absence of eosinophils.[11] The patient reported no history of medication use, which would represent an alternative explanation for the biopsy findings. In this case, the authors would argue that the eruption was due to a hypersensitivity to the tattoo ink. To the authors’ knowledge, this is the first reported case of a generalized lichenoid reaction to a tattoo containing only black ink.
The mechanism underlying generalized tattoo reactions is unknown, but there are two leading theories. The first hypothesis is that the inciting agent in the tattoo ink may disseminate to distant body sites and elicit a response. The second hypothesis is akin to an “id reaction,” in which a localized dermatitis stimulates the immune system to cause a similar skin eruption at distant sites.[9] One case of a generalized tattoo reaction was noted to resolve with topical steroids only, but other cases have required systemic steroids, phototherapy, or hydroxychloroquine.[9] Interestingly, the use of lasers for tattoo removal in cases of localized tattoo reactions may incite a generalized eruption, perhaps due to ink particles being released into the extracellular space, leading to an even more robust immune response.[6,9,12,13] This suggests that the use of laser tattoo removal to treat an already generalized tattoo reaction would be ill-advised. Unfortunately in some refractory cases, surgical excision is the best option.
There are several limitations to this article. This is a case report of a single patient, which is based for the most part upon oral history. The biopsy findings, while suggestive of a generalized lichenoid reaction to tattoo ink, are non-specific, and it is not possible to link definitively the clinical findings of the rash with the history of the tattoo. Additionally, the patient was lost to follow-up, and it is not known whether he improved with the treatment course prescribed. Nonetheless, this case report contributes to a growing body of literature documenting the many risks of tattoos, particularly in the adolescent population.[1]
Figure 4
Figure 5

References
1.     Juhas E, English J. Tattoo-associated complications. J Pediatr Adolesc Gynecol. 2013;26(2):125–129.
2.    Deschechnes M, Demers S, Fines P. Prevalence and characteristics of body piercing and tattooing among high school students. Can J Public Health. 2006;97(4):325–329.
3.    Ortiz AE, Alster TS. Rising concern over cosmetic tattoos. Dermatol Surg. 2012;38(3):424–429.
4.    Jacob CI. Tattoo-associated dermatoses: a case report and review of the literature. Dermatol Surg. 2002;28(10):962–965.
5.    Kaur RR, Kirby W, Maibach H. Cutaneous allergic reactions to tattoo ink. J Cosmet Dermatol. 2009;8:295–300.
6.    Tanzi EL, Elston DM. Tattoo reactions. http://emedicine. medscape.com/article/1124433. Last updated August 2011.
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8.    Goldberg HM. Tattoo allergy. Plast Reconstr Surg. 1996;98: 1315–1316.
9.    Litak J, Ke MS, Gutierrez MA, et al. Generalized lichenoid reaction from tattoo. Dermatol Surg. 2007;33(6):736–740.
10.    Taaffe A, Wyatt EH. The red tattoo and lichen planus. Int J Dermatol. 1980;19:394–396.
11.    Brinster NK, Liu V, Diwan AH, McKee PH, eds. Dermatopathology. Philadelphia: Saunders; 2011:48–51.
12.    Harper J, Losch AE, Otto S, et al. New insight into the pathophysiology of tattoo reactions following laser tattoo removal. Plast Reconstr Surg. 2010;126(6):313e–314e.
13.    Zemtsov A, Wilson L. CO2 laser treatment causes local tattoo allergic reaction to become generalized. Acta Derm Venereol. 1997;77(6):497.

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