CASE STUDY - ALLERGIC CONTACT DERMATITIS IN RELATION TO TATTOOS
Keywords:Allergic contact dermatitis, Tattoo ink, red pigment, Laser removal therapy, Q-switched Nd laser, Treatment with systemic corticosteroids
As tattooing becomes more and more popular, growing numbers of skin reactions caused by tattoos are also becoming frequently encountered by medical professionals. We present a generic case of a tattoo-induced allergic reaction and explore its’ immunological mechanism. This paper also highlights components of tattoo inks, their allergenic potential, and possible options for treatment. There can be different types of allergens in tattoo inks. Some are biodegradable, while others are not. Examples of biodegradable components include natural dyes and preservatives. Allergic reactions caused by such agents may resolve with simple therapy since after a short period they will be cleared from the skin. On the other hand, synthetic molecules and other non-degradable dyes will need invasive therapy, such as surgery, dermatome shaving and most commonly used - laser removal therapy. Most notable in this regard is red ink with the highest incidence. There are no current regulations on tattoo inks, which puts tattoo enthusiasts at a higher risk of developing allergic reactions. There are certain preventive measures, such as patch and dot tests. Because the specificity of these tests is mediocre, despite negative results, an allergic reaction may develop weeks or months later. There are no strict treatment guidelines and each case must be assessed individually. Our patient was a young woman, who developed a local allergic reaction due to the red pigment used in her tattoo. Initial treatment, in this case, was anti-inflammatory to reduce inflammation. The only way to get full resolution in such cases is to remove the allergen (red pigment) from the dermis. The patient was prescribed topical treatment with corticosteroids. Once irritation subsided tattoo removal therapy with Q-switched Nd 532 nm laser was initiated. The inflammation returned after the first session, for which local anti-inflammatory medications were started. Due to the ineffectiveness of laser removal and local treatments systemic therapy with corticosteroids was prescribed with gradually decreasing the dosage and controlling the disease. After two months of this treatment, the patient's condition improved. She is still undergoing therapy with systemic corticosteroids.
Antony FC, Harland CC. Red ink tattoo reactions: successful treatment with the Q-switched 532 nm Nd:YAG laser. Br J Dermatol. 2003;2016;149(1):94–8.
Ashinoff R, Levine VJ, Soter NA. Allergic reactions to tattoo pigment after laser treatment. // Dermatol Surg. 1995;21(4):291–4.
Bassi A, Campolmi P, Cannarozzo G, Conti R, Bruscino N, Gola M, Ermini S, Massi D, Moretti S. Tattoo-Associated Skin Reaction: The Importance of an Early Diagnosis and Proper Treatment // Published online, Biomed Res Int. 2014; 354608.
Bent S.A.S, Huisman S. Ablative laser surgery for allergic tattoo reactions: a retrospective study // Lasers in Medical Science; 26 Oct. 2020; 36:1241-1248.
Bolognia Jean L, Schaffer JV, Cerroni L. Allergic Contact Dermatitis // Dermatology Fourth Edition; 2014; 242-261.
Bonefeld C. Allergy and Tattoos // The Danish Environmental Protection Agency. Environmental Project N 1945, June 2017, 5-33.
Brady BG, Gold H, Leger EA, Leger MC. Self-reported adverse tattoo reactions: a New York City Central Park study. Contact Dermatitis. 2015 Aug;73(2):91-9.
Cruz FAM, Lage D, Frige´rio RM, et al. Reactions to the different pigments in tattoos: a report of two cases. An Bras Dermatol. 2010;85(5):708–11.
Cuyper C de, Pérez-Cotapos M-L, eds. Dermatologic Complications with Body Art, Tattoos, Piercings and Permanent Make-Up. Heidelberg: Springer Verlag, 2010.
Dikicier BS, Yaldiz M, Cetinkaya R, Erdem T. Tattoo Associated Allergic Contact Dermatitis // Austin J Dermatolog. 2015; 2(2): 1037.
Dybboe R, Linneberg A, Johansen JD. Tattooing and adverse reactions in adults from the general population. P077. ESCD Abstracts: Posters. Contact Dermatitis 2016:75:S1:60–106.
Feldstein S, Jadgeo J. Successful Medical Treatment of a Severe Reaction to Red Tattoo Pigment // Journal of Drugs In Dermatology; Oct. 2014; 13(10):1274-1275.
Forbat E, Al-Niaimi F. Patterns of Reactions to Red Pitment Tattoo and Treatment Methods // Dermatology and Therapy; Springerlink.com; March 14, 2016.
Hsu VM, Aldahan AS, Mlacker S, Shah VV, Nouri K. The picosecond laser for tattoo removal. Lasers in Medical Science; 2016; 31:1733–7. DOI: 10.1007/s10103-016-1924-9.
Kaplan DH, Kissenpfennig A, Clausen BE. Insights into Langerhans cell function from Langerhans cell ablation models. Eur J Immunol 2008; 38:2369.
Kuperman-Beade M, Levine VJ, Ashinoff R. Laser removal of tattoos // Am J Clin Dermatol. 2001;2(1):21-5.
Murphy P.B, Atwater A.R, Mueller M. Allergic Contact Dermatitis // Statpearls publishing; University of California San Diego, 20 Sep. 2021.
Piccinini P, Pakalin S, Contor L, Bianchi I, Senaldi C. JRC science for policy report: safety of tattoos and permanent make-up final. European commision technical report 2016
Renzoni A, Pirrea A, Novello F, et al. The tattooed population in Italy: a national survey on demography, characteristics and perception of health risks. Ann Ist Super Sanita. 2018;54(2):126-136.
Rustemeyer T, Hoogstraten I.M.W, Blomberg B.M.E, Scheper R.J. Mechanisms in Allergic Contact Dermatitis // Kanerva's Occupational Dermatology. 2012; pp. 113-146.
Saunders H, O’Brien T, Nixon R. Textile dye allergic contact dermatitis following paraphenylenediamine sensitization from a temporary tattoo // Australas J Dermatol. 2004;45(4):229–31.
Seitxe A-T, Grunewald S, Wagner JA, Simon Jan C, Paash U. Fractional CO2 laser is as effective as Q-switched ruby laser for the initial treatment of traumatic tattoo // J Cosmet Laser Ther. 2014 Dec;16(6):303-5.
Sepehri M, Jørgensen B, Serup J (2015) Introduction of dermatome shaving as first line treatment of chronic tattoo reactions. J Dermatolog Treat 26:451–455.
Serup J, Baumler W. Guide to Treatment of Tattoo Complications and Tattoo Removal // Curr Probl Dermatol. 2017;52:132-138.
Serup J, Carlsen KH, Dommershausen N, Sepehri M, Hesse B, Seim C, Luch A, Schreiver I. Identification of pigments related to allergic tattoo reactions in 104 human skin biopsies // Published online, Wiley Contact Dermatitis, 2020 Feb; 82(2): 73–82.
Serup J, Hutton Carlsen K. Patch test study of 90 patients with tattoo reactions: negative outcome of allergy patch test to baseline batteries and culprit inks suggests allergen(s) are generated in the skin through haptenization. Contact Dermatitis. 2014;71(5):255–263. doi: 10.1111/cod.12271.
Serup J, Sepehri M, Carlsen KH. Classification of Tattoo Complications in a Hospital Material of 493 Adverse Events // Epub 15 Dec. 2016, 232(6):668-678.
Schmitz I, Prymak O, Epple M, Ernert C, Tannapfel A. Squamous cell carcinoma in association with a red tattoo. J Dtsch Dermatol Ges. 2016 Jun;14(6):604-9. doi: 10.1111/ddg.12730. PubMed PMID: 27240068.
Tang MM, Beltranimelli H, Perruchoud D. A tattoo complicated by allergic contact dermatitis and pannicultis. Journal of the European Academy of Dermatology and Venereology. 2014;28(1):127–128.
Vocanson M, Hennino A, Rozieres A, Poyet G, Nicolas J-F. Effector and regulatory mechanisms in allergic contact dermatitis // Allergy – European Journal Of Allergy And Clinical Immunology; Epub 2009, Oct 12.
Wang X, Josefsson L, Meschnark S, Lind M-L, Emmer A, Goessler W, Hedberg YS. Analytical survey of tattoo inks – A chemical and legal perspective with focus on sensitizing substances // The official publication of the European Society of Contact Dermatitis. Sept. 2021, 340-353.
Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ. Allergic Contact Dermatitis // Fitzpatrick’s Dermatology in General Medicine, Seventh Edition; 135-146.