Eyelid margin tattoo granuloma in an individual with systemic sarcoidosis

Systemic sarcoidosis rarely presents as tattoo granulomas. We present a case of an eyelid tattoo granuloma as a prodrome to the diagnosis of sarcoidosis; this case is unique in its onset being several decades following the initial tattooing event, in addition to its resolution with intralesional triamcinolone. A 63-year-old female presented with ipsilateral upper and lower lid margin tattoo granulomas, 6 months post bilateral conjunctivitis. A punch biopsy of the granuloma revealed dermal non-caseating granulomatous inflammation. Serum angiotensin-converting enzyme levels were elevated, and a computed tomography scan revealed pulmonary lymphadenopathy, in keeping with a diagnosis of sarcoidosis. The granulomas resolved with a combination of intralesional triamcinolone and topical hydrocortisone ointment. The differential diagnosis for tattoo-associated granulomatous lesions is broad. This case report highlights the importance of biopsy and appropriate investigations for tattoo granulomas, as it may be the only sign of a systemic condition such as sarcoidosis.