Granulomatous Lesions Over Tattoos: Is It Sinister or Benign?

Dear Madam, Sarcoidosis is a granulomatous disease of unknown etiology, affecting multiple organ systems. Mucocutaneous involvement has been noted in up to one-third of patients with sarcoidosis.[1] The development of cutaneous lesions within tattoos is a well-recognized finding in patients with sarcoidosis. These cutaneous reactions have been described to occur in various colors of multi-pigmented tattoos as well as limited to a particular color of multi-pigmented tattoos. While the involvement of a single pigment may convey the presence of an allergic response to a pigment, this is not a consistent finding on which to eliminate a diagnosis of cutaneous sarcoidosis.[1] A young male in his early thirties presented to our hospital with a complaint of asymptomatic reddish raised lesions over the tattoo area on his right arm (placed 10 years ago), appearing for the last 2–3 months and increasing in number; initially smooth with appearance of scaling after application of some topical medication. On examination, there were multiple well to ill-defined translucent erythematous papules and nodules with whitish loosely adherent scales over some lesions, present only over tattoo pigment lines diffusely [Figure 1a]. Lesions were suggestive of granulomatous pathology clinically so we thought of tattoo sarcoidosis, foreign-body granulomas, and granulomatous contact dermatitis as differential diagnoses and performed a punch biopsy for histopathological examination; which revealed discrete noncaseating naked epithelioid cell granulomas in the upper dermis (no foreign bodies visualized) [Figure 1b-d], thus confirming a diagnosis of sarcoidosis. On further workup, chest X-ray, liver function test, kidney function test, serum angiotensin convertase enzyme levels, serum and urine calcium, and Vitamin D levels were within normal limits. The ophthalmological evaluation did not reveal any involvement. Thus, the systemic disease was ruled out. The patient was started on topical mid-potency corticosteroids and capsule doxycycline 100 mg twice daily for 6 weeks with cessation of progression and partial resolution of lesions at follow-up.Figure 1: (a) Multiple well-defined translucent erythematous papules and nodules with loosely adherent whitish scales over some lesions, present over tattoo pigment lines over the right arm. (b) Histopathological examination (HPE) image showing well-defined rounded areas of inflammatory infiltrate in the upper dermis (H and E, ×4). (c) HPE image at higher power view showing well-defined naked discrete granulomas (×40). (d) High power (×100) micrograph showing multiple epithelioid cells in the granuloma with an absence of caseation and foreign bodiesIn 1955, Obermayer and Hassen reported the first case of a sarcoid reaction within a tattoo found to be a manifestation of systemic sarcoidosis.[1] There is a limited number of recognized cases of tattoo-induced sarcoidosis in the past 75 years. The pathophysiology is not yet very clear. The most accepted hypothesis is “pigment-induced disease.” It is theorized that tattoo pigments induce chronic antigenic stimulation resulting in an imbalance of Th1/Th2 in an innately predisposed patient finally triggering sarcoidosis. It was expected for pigment-induced tattoos only to cause cutaneous sarcoidosis. Still, in 2005, the tattoo sarcoidosis cases were reviewed via meta-analysis and it was determined that most cases (14/19) had pulmonary involvement with the tattoo reaction.[2] Given these findings, inflamed tattoos may be manifestations of sarcoidosis and not causative agents. Granulomatous reactions following tattoos are rare but should be considered in the differential diagnosis, and once confirmed, systemic sarcoidosis should be investigated.[3] Other tattoo site histopathological reaction patterns include lichenoid, morphea-like, pseudo-epitheliomatous hyperplasia, and allergic and photoallergic contact dermatitis. Management options are based on the extent of involvement, only cutaneous lesions respond well to topical corticosteroids and systemic disease can be treated with conventional agents including oral corticosteroids, doxycycline, hydroxychloroquine, methotrexate, or newer agents including oral tumor necrosis factor alpha inhibitors. Tattoos are generally considered harmless, though, adverse reactions including allergic reactions, infections (especially in amateur tattoos), and autoimmune diseases may occur. The importance of reporting this case lies in the fact that these cutaneous tattoo reactions may be associated with systemic sarcoidosis also, so a workup to assess various systems is necessary and is being stressed here. Declaration of consent The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s)/guardian(s) of the patient. In the form, the parent(s)/guardian(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child/children will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.