Generalized Lichenoid Reaction from Tattoo

Generalized Lichenoid Reaction from Tattoo JASON LITAK, BS, MALCOLM S. KE, MD, MIGUEL A. GUTIERREZ, MD, TERESA SORIANO, MD, GARY P. LASK, MD AND The authors have indicated no significant interest with commercial supporters. attooing has been a cultural practice for thousands of years, in many parts of the world, and across many civilizations. Decorative tattooing involves the introduction of foreign substances, also known as tattoo pigments, into the skin. This process has been associated with various types of cutaneous eruptions known as ‘‘tattoo reactions.’’ The most common type of tattoo reaction is a localized lichenoid tissue reaction, with involvement confined T to the areas of the tattoo. This reaction pattern is most commonly seen in tattoos with red pigmentation.1–7 Generalization of this lichenoid tattoo reaction to involve distant sites has only been reported in three cases.8–10 We present the fourth case of a generalized lichenoid reaction to a tattoo. A review of the literature including the risks of treating tattoo reactions with lasers will also be discussed. Figure 1. Tattoo and lower leg. Figure 2. Contralateral leg. Division of Dermatology, University of California, Los Angeles, California & 2007 by the American Society for Dermatologic Surgery, Inc.  Published by Blackwell Publishing  ISSN: 1076-0512  Dermatol Surg 2007;33:736–740  DOI: 10.1111/j.1524-4725.2007.33153.x 736 L I TA K E T A L Case Report A 36-year-old Latino woman complaining of a generalized cutaneous eruption presented to the Dermatologic Surgery and Laser Center at the University of California, Los Angeles (UCLA), in the spring of 2006. Approximately 6 years before presentation, she underwent coloring of her black tattoo, which had been asymptomatic and present for 10 years. The coloring consisted of red, orange, yellow, and purple flowers. Approximately 1 year after the coloring of her tattoo, she developed pruritic papules coalescing into plaques over three purple flowers of her tattoo. Over the next 5 years, the purple flowers faded to magenta, and the eruption progressed to involve the left shin, followed by distant sites: the contralateral leg, elbows, and lower back. Previous treatments with topical, intralesional and systemic steroids were temporizing, but not curative, with eventual progression of her disease. The patient was otherwise healthy with a past medical history significant for hypothyroidism. Her only medication was levothyroxine. She had no allergies or history of psoriasis or atopic dermatitis. On physical exam, the patient was a healthyappearing Latino woman. Over the left ankle was an ankletlike tattoo of colored flowers involving a 1-in. ring of skin around her ankle. Over the magenta-colored flowers were indurated plaques. There were scattered flat-topped erythematous papules over her bilateral lower extremities (Figures 1 and 2). In addition, she was developing new lesions over her elbows (Figure 3) and lower back (Figure 4). Her wrists, oral mucosa, and scalp were unremarkable. Hepatitis panels were negative. A biopsy of a representative lesion from the right shin revealed a compact stratum corneum, a normalthickness epidermis with focal flattening of the rete ridges, scattered Civatte bodies, and a lichenoid tissue reaction composed of lymphocytes in the upper dermis. Figure 3. Elbow. Medical therapy was initiated with hydroxychloroquine considering the progressive and generalizing nature of her lichenoid tissue reaction. In addition, she was referred to the Plastic and Reconstructive Surgery Department at UCLA for evaluation of surgical excision of her ankle tattoo, followed by graft placement. Discussion Welander12 first described reactions to tattoos in 1893. Various histopathologic types of reactions have been described, including lichenoid, photoallergic, granulomatous, pseudolymphomatous, and Figure 4. Lower back. 33:6:JUNE 2007 737 G E N E R A L I Z E D L I C H E N O I D R E A C T I O N F R O M TAT T O O even sarcoidal. Of these types, the lichenoid tissue reaction is the most commonly reported. tattoo reactions varies from a few weeks to more than 10 years. Each color of tattoo ink contains different substances that potentially have different types and incidences of adverse reactions. Red tattoos are best recognized to cause reactions. Inciting agents in red tattoo ink may include mercuric sulfide, also known as ‘‘cinnabar,’’ organic substances such as aromatic azo derivatives13 or even nickel.7 Reactions to purple tattoos have rarely been reported.14–16 Manganese is thought to be the inciting agent, and these reactions have mostly been reported as the granulomatous type.14,15 Based on our review of the literature to date, this is the first reported case of a generalized lichenoid reaction occurring from a purple tattoo. The exact pathophysiology of generalized tattoo reactions remains unknown, but two main theories exist. First, the inciting agent in the tattoo may disseminate to other parts of the body and elicit eruptions distant to the initial site. Such is the case of systemic sarcoidosis caused by extensive tattooing over the trunk and arms, in which tattoo pigments were identified in the sarcoidal granulomas within the lungs of the patient.17 Generalized lichenoid reactions involving tattoos have been reported in three other cases.8–10 In 1952, Rook and Thomas11 briefly acknowledged that lichen planus can undergo a Koebner isomorphic phenomenon from tattoos, but the exact details behind these claims were not fully described. Taaffe and Wyatt8 reported a case of generalized lichen planus that shared a temporal relationship with a more severe lichenoid reaction in several red tattoos in a metal smeltery worker who had a long exposure to mercury metal fumes. Goldberg9 reported a case of a generalized lichenoid reaction appearing after the placement of a tattoo composed of black, blue, red, and green colors that improved with surgical removal of the tattoo. Dang and colleagues10 reported a lichen planus reaction that started in the red areas of a tattoo and on the patient’s glans penis and progressed to involve his arms and legs, but resolved after a 4-week course of topical steroids.10 The varied time course of the tattoo reactions in these cases is interesting. Dang and colleagues10 and Goldberg9 both reported the reaction appearing 1 month after tattoo placement. In our case, the reaction appeared 1 year after the placement of the tattoo. Taaffe and Wyatt8 reported a reaction arising in tattoos that were at least 14 years old. This suggests, as noted by Goldberg,9 that the time interval of 738 D E R M AT O L O G I C S U R G E RY The second explanation for tattoo reactions becoming generalized may relate to an ‘‘id reaction.’’ The id reaction, also known as autoeczematization, autosensitization, or papular urticaria, is defined as diffuse, symmetric spread of a morbilliform eruption of a previously localized dermatitis.18 The assumption in the id reaction is a hypersensitivity that stimulates the immune system causing distant skin eruptions, without the inciting agent present at the distant sites. Ashinoff and colleagues25 reported a biopsy showing spongiosis consistent with an id reaction in a generalized rash after the treatment of a tattoo with the Nd:YAG laser. The id reaction, or autoeczematization, can have a spongiotic histopathology or can have varied histopathologic features that mimic those seen in the initial lesions.19 Despite the pathophysiology of particular tattoo reactions, it is the treatment that carries the bulk of clinical relevance and importance to affected patients. Immune modulation with steroids is useful as initial therapy. In fact, the generalized lichen planus tattoo reaction reported by Dang and coworkers10 resolved with the use of topical corticosteroids alone. In our case, however, steroids used in various modalities were insufficient. Medical therapy for generalized lichen planus typically includes systemic steroids, phototherapy, hydroxychloroquine, thalidomide, and recently reported alefacept. In refractory cases such as ours, it may be necessary to remove the offending tattoo. Although the L I TA K E T A L gold standard in tattoo removal with the least adverse effects is the Q-switched laser, its use in the setting of lichenoid tattoo reactions, and especially in the setting of generalized reactions, is highly debatable. There have been countless benign tattoos removed with lasers. There have only been five successful reports using lasers to treat tattoos complicated by tattoo reactions, however.20–24 Three involved treatment with the Nd:YAG laser,20–22 one with the erbium:YAG laser,23 and one with the CO2 laser.24 These cases give hope to the utility of lasers in treating tattoo reactions. All of these cases treated localized eruptions only, however. There have been no reported cases of successful laser treatment of tattoos with generalized tattoo reactions. In addition, it has been reported that the use of lasers for tattoo removal may actually cause generalized tattoo reactions.25–27 Ashinoff and colleagues25 described two cases of a generalized eruption appearing after tattoo removal using both the Q-switched ruby laser and the Q-switched Nd:YAG laser.25 England and colleagues26 reported the case of an immediate cutaneous hypersensitivity reaction after treatment of an otherwise asymptomatic tattoo with the Nd:YAG laser. Zemtsov and Wilson27 reported a case in which treatment of a local tattoo reaction with the CO2 laser caused the reaction to become generalized. It is notable that even the water-targeting CO2 laser, which does not target tattoo pigment like the Nd:YAG, has been reported to cause enough dissemination of tattoo pigment to cause a generalized reaction. Similarly, it is likely that treatment with the Er:YAG laser may also carry this risk. The pigment-targeting Nd:YAG laser may disseminate tattoo pigment even more and may be even more likely to cause a generalized reaction. These cases suggest that using lasers on tattoos that have undergone a tattoo reaction can carry a significant risk. Of particular concern is the risk of creating a generalized reaction pattern after laser treatment of a localized area. Therefore, it would appear that the risk involved in attempting to treat a tattoo reaction that has already become generalized would dramatically increase. Laser treatment in the setting of a generalized tattoo reaction may cause further dissemination and worsening of that reaction. Therefore, we opted not to treat our patient with lasers. Instead, we elected to initiate medical therapy with hydroxychloroquine due to the progressive and generalizing nature of her lichenoid tissue reaction and to refer her for evaluation for surgical excision of her tattoo. It behooves the dermatologist to recognize these risks in the laser treatment of tattoos and to use caution when treating tattoo reactions. In persistent tattoo reactions, along with various medical therapies, removal of the offending tattoo may be necessary. In these cases, surgical excision is a better option than lasers for individuals who have already shown a propensity to adverse reactions from tattoo pigments. References 1. Sowden JM, Byrne JP, Smith AG, et al. Red tattoo reactions: X-ray microanalysis and patch-test studies. Br J Dermatol 1991;124:576–80. 2. Clarke J, Black MM. Lichenoid tattoo reactions. Br J Dermatol 1979;100:451–4. 3. Winkelmann RK, Harris RB. Lichenoid delayed hypersensitivity reactions in tattoos. J Cutan Pathol 1979;6:59–65. 4. Taaffe A, Knight AG, Marks R. Lichenoid tattoo hypersensitivity. Br Med J 1978;1:616–8. 5. Mortimer NJ, Chave TA, Johnston GA. Red tattoo reactions. Clin Exp Dermatol 2003;28:508–10. 6. Bhardwaj SS, Brodell RT, Taylor JS. Red tattoo reactions. Contact Dermatitis 2003;48:236–7. 7. Corazza M, Zampino MR, Montanari A, et al. Lichenoid reaction from a permanent red tattoo: has nickel a possible aetiologic role? Contact Dermatitis 2002;46:114–5. 8. Taaffe A, Wyatt EH. The red tattoo and lichen planus. Int J Dermatol 1980;19:394–6. 9. Goldberg HM. Tattoo allergy. Plast Reconstr Surg 1996;98: 1315–6. 10. Dang M, Hsu S, Bernstein E. Lichen planus or lichenoid tattoo reaction? Int J Dermatol 1998;37:860–1. 11. Rook A, Thomas P. Social and medical aspects of tattooing. Practitioner 1952;169:60. 33:6:JUNE 2007 739 G E N E R A L I Z E D L I C H E N O I D R E A C T I O N F R O M TAT T O O 12. Welander E. Falle von Keloid. Nord Med Arkiv (Stockh) 1893;3:1. 13. Bendsoe N, Hansson C, Sterner O. Inflammatory reactions from organic pigments in red tattoos. Acta Derm Venereol (Stockh) 1991;71:70–3. 14. Schwartz RA, Mathias CG, Miller CH, et al. Granulomatous reaction to purple tattoo pigment. Contact Dermatitis 1987;16:198–202. 15. Nguyen LQ, Allen HB. Reactions to manganese and cadmium in tattoos. Cutis 1979;23:71–2. 16. Balfour E, Olhoffer I, Leffell D, Handerson T. Massive pseudoepitheliomatous hyperplasia: an unusual reaction to a tattoo. Am J Dermatopathol 2003;25:338–40. 22. Dave R, Mahaffey PJ. Successful treatment of an allergic reaction in a red tattoo with the Nd-YAG laser. Br J Plast Surg 2002;55:456. 23. De Argila D, Chaves A, Moreno JC. Erbium: Yag laser therapy of lichenoid red tattoo reaction. J Eur Acad Dermatol Venereol 2004;18:332–3. 24. Kyanko ME, Pontasch MJ, Brodell RT. Red tattoo reactions: treatment with the carbon dioxide laser. J Dermatol Surg Oncol 1989;15:652–6. 25. Ashinoff R, Levine VJ, Soter NA. Allergic reactions to tattoo pigment after laser treatment. Dermatol Surg 1995;21: 291–4. 17. Hanada K, Chiyoya S, Katabira Y. Systemic sarcoidal reaction in tattoo. Clin Exp Dermatol 1985;10:479–84. 26. England RW, Vogel P, Hagan L. Immediate cutaneous hypersensitivity after treatment of tattoo with Nd: YAG laser: a case report and review of the literature. Ann Allergy Asthma Immunol 2002;89:215–7. 18. Belsito DV. Autosensitization dermatitis. In: Fitzpatrick’s dermatology in general medicine, 5th ed. New York: McGraw-Hill, 1999:p. 1462–4. 27. Zemtsov A, Wilson L. CO2 laser treatment causes local tattoo allergic reaction to become generalized. Acta Derm Venereol 1997;77:497. 19. Weedon D. Skin pathology. Amsterdam: Elsevier Science, 2002. 20. Hindson C, Foulds I, Cotterill J. Laser therapy of lichenoid red tattoo reaction. Br J Dermatol 1995;133:665–6. 21. Antony FC, Harland CC. Red ink tattoo reactions: successful treatment with the Q-switched 532 nm Nd:YAG laser. Br J Dermatol 2003;149:94–8. 740 D E R M AT O L O G I C S U R G E RY Address correspondence and reprint requests to: Jason Litak, BS, 1625 Glendon Avenue, #3 Los Angeles, CA 90024, or e-mail: [email protected]