Chronic eczematous reaction to red tattoo

zyxwvu zyx zyxwvut zyxwvutsrq zyxwvutsr Letters to the Editor cular slits suggest lymphatic involvement. The negativity of the alkaline phosphatase reaction in THH may also indicate a lymphatic origin [1,4]. In our opinion, the emergence of the hemangiomatous appearance and the ecchymotic halo in patients with THH lesion may be caused by trauma [3] as in hematolymphangioma circumscriptum, or hormonal factors [6] as reported previously. Oktay Avci"*, Mahmut Ciineyt Soyal",Ozgiil Sakolb,Ali T h i n Gunes" 'Department of Dermatology, Dokuz Eyliil University, Faculty of Medicine, Inciralti, 35340 Izmir, Turkey bDepartment of Pathology, Dokuz Eyliil University, Faculty of Medicine, Inciralti, 35340 Iztnir, Turkey A 25-year-old man was seen in our institute complaining of an intensely itchy cutanpous reaction, limited to the red areas of his right arm tattoo, which had been performed 1 year Drior to our examination (Fig. 1). Dermatitis appeared with a lag-time of 6 months and started after sun exposure. The reaction was steady but with periods of exacerbation (increased itching and oozing) not always related to Uv-stimulation. The patient was in good health and he denied a history of allergy. Patch testing (GIRDCA series, plus red pigments, a complex mixture of unknown constituents, obtained from the patient's tattooist, pure and 10% in water) was negative. Results of a complete blood count and chemistry (including lymphocyte subpopulation quantification) were negative or within normal limits. Topical and systemic steroid treatment was uneffective, due to relapses when steroids were stopped. The therapeutic choice was a surgical elliptic excision of the tattoo and repair through direct suture of the edges (Fig. 2). Regular course and complete healing was obtained. Histology showed acanthosis with severe spongiosis; an infiltrate of lymphocytes was noticed in the upper and middle dermis, associated with rare giant cells. Pigment was found to lay close to the capillaries. The girl friend of the patient exhibited the same tattoo, in the same site, performed in the same time, but without reactions. Allergic reaction caused by red tattoos have usually been attributed to mercury hypersensitivity [7]. Alternative mercury-free red dyes have been used, including cadmium selenide, femc hydrate and organic substances (e.g. sandalwood) [7,8]. In spite of that, reactions to red tattoos continue to be zyxwvuts zyxwvutsrq zyxwvutsrqp [l] Santa Cruz DJ, Aronberg J. Targetoid hemosiderotic hemangioma. J Am Acad Dermatol 1988;19:550-558. [2] Pemn C, Rodot S, Ortonne JP,et al. L'himangiome en cible hCmosid6rinique. Ann Dermatol Venereol 1995;122:1 1 1114. [31 Rapini PR, Golitz LE. Targetoid hemosiderotic hemangioma. J Cutan Pathol 1990;17:233-235. [4] Vion B, Frenk E. Targetoid hemosiderotic hemangioma. Dermatology 1992;184:300-302. [5] Krahl D, Petzoldt D. Targetoides Haemosiderotisches Haemangiom. Eine weitere Differentialdiagnose des Kaposi-Sarkoma. Hautarzt 1994;45:34-37. [6] Morganroth GS, Tigelaar RE, Longley BJ, et al. Targetoid hemangioma associated with pregnancy and the menstrual cycle. J Am Acad Dermatol 1995;32:282-284. PII SO926-9959(98)00047-6 *Corresponding author. Tel.: +90 232 2595959; fax: +90 232 277 12I I . Chronic eczematous reaction to red tattoo Letter to the Editor: Tattooing has been practised for several centuries and remains a frequent practice in our country and in various cultures. The introduction of various substances into the skin can originate an imtant or immunological response [l]. Several types of adverse reactions to tattoo pigments have been described. These manifestations include lichenoid [2] or granulomatous reactions [3,4]; occasionally the histological pattern suggests a diagnosis of pseudolymphoma [ 5 ] . Discoid lupus erythematosus can appear in areas with red tattoos [6]. zyxwvuts Fig. 1. Eczematous reaction is seen in the red portion of the tattoo. Letters to the Editor investigators that further studies are necessary to distinguish photoallergic from phototoxic reactions. The tattoo performed simultanemsly, and therefore with the same red pigment, in our patient and in his girl friend, who exhibited no reaction, not even after sun exposure, seems to suggest the possibility of a photoinduced mechanism. zyxwv Paolo Pauluzzia*,Mauro Giordani”,Gianni Franco Guamerib, Michele Pasconeb “Institute of Dermatology, University of Trieste, Ospedale di Cattinara - Strada per Fiume, 34149 Trieste, Italy bCattedra di Chirurgia Plastica e Ricostruttiva, Universita di Trieste, Italy [ l ] Goldstein N. Tattoos. J Dermatol Surg Oncol 1979;5:851856. [2] Taafe A, Knight AG, Marks R. Lichenoid tattoo hypersensitivity. Br Med J 1978;1:616-618. 131 Schwartz RA, Mathias CG, Miller CH, Rojas-Corona R, Lambert C. Granulomatous reaction to purple tattoo pigment. Contact Dermatitis 1987;16 198-202. [4] Rorsman H, Dahlquist I, Jacobson M, Brehmer-Anderson E, Ehinger B, Linell F. Tattoo granuloma and uveitis. Lancet 1969;ii:27-28. [5] Blumental G, Okun MR, Panitch JA. Pseudolymphomatous reaction to tattoo. J Am Acad Dermatol 1982;6:485-488. [6] Hall AF. Lupus erythematous in red part of tattooed area. Arch Derm Syph 1943;47:610-611. [7] Bendson N, Hansson C , Sterner 0. Inflammatory reactions from organic pigments in red tattoos. Acta Derm Venereol (StOCkh) 1991;7 1:70-73. [8] Kozuka T, Tashiro M, Sano S. Pigmented contact dermatitis from azo dyes cross sensitivity in humans. Contact Dermatitis 1980;6:330-336. [9] Sowden JM, Byrne JP, Smith AG, Hiley C, Suarez V, Wagner B, Slater DN. Red tattoo reactions X-ray microanalysis and patch test studies. Br J Dermatol 1991;124:576-580. [lo] Abel EA, Silberberg I, Queen D. Studies of chronic inflammation in a red tattoo by electron microscopy and histochemistry. Acta Derm Venereol (Stockh) 1972;52:453-461. zyxw zyxwvutsr zyxwvu Fig. 2. The patient’s arm 3 months after surgery. zyxwv zyxwvut zyxwvu described. In our patient and in several series patch testing showed negative reactions to mercury and the red pigments used in their tattoos [9]. The reaction may be caused-by an inflammatory response triggered by the substance within the dermis, and epicutaneous testing has been reported not to be appropriate [lo]. A dermal sensitivity was not confirmed, because the patient refused intradermal skin testing, and furthermore we felt that intracutaneous testing was against our code of conduct. The presence of the same tattoo, without reaction, in the patient’s girl friend, seems to exclude responsibility of an irritant mechanism and seems to confirm an allergic pathogenesis. Most patients, who exhibit a reaction to the red pigment, state that the manifestations started after UV-exposure . Sowden et al. [8] reported that in their series 7 patients noticed that their red tattoos became more inflamed with sun exposure, and three of these attributed the onset of their tattoo reactions to sunlight. We agree with these PII SO926-9959(98)00053-1 *Corresponding author. Tel.: +39 40 3994327; fax: +39 40 9 10690. Short-term treatment of pityrosporum folliculitis: a double blind placebo-controlled study To the Editor: Pityrosporum folliculitis is a clinically distinct condition most often seen in young