Intralesional Corticosteroids in the Management of Red Tattoo Granulomas: A Clinicopathological Perspective

Sir, Tattoo pigment can cause various inflammatory conditions, with the skin being the most common site. However, the ink can also get disseminated and trigger systemic inflammation, and the effectiveness of treatments varies depending on the severity and extent of the reaction.[1] Allergic reactions from tattoos can occur with almost every color, but red tattoos are most commonly associated with such reactions.[2] Granulomatous reactions to tattoo ink are primarily caused by mercury sulfide, a component found in red pigments. Treatment options for this condition are limited, and some of the potential therapies include topical and intralesional corticosteroids, surgical removal, cryotherapy, and laser treatment.[3] We report the rare case of a 25-year-old male diagnosed with tattoo granuloma, based on histopathology, and effectively treated with intralesional triamcinolone acetonide. A 25-year-old male presented to us with mild itching and the development of red, raised lesions over the tattoo on his right forearm for 1 month, inked at a local parlor 4 months ago. On examination, a few shiny, erythematous, nontender papules and plaques were observed on his right forearm, restricted to red tattoo portions. In contrast, the area with green ink and normal skin around the tattoo remained unaffected [Figure 1a]. These lesions were not associated with fever, malaise, joint pains, lymphadenopathy, or any other systemic symptoms. Histopathological findings were consistent with epidermal hyperplasia, dermal fibrosis, and a lymphohistiocytic, nonsarcoid, granulomatous infiltrate surrounding the red tattoo pigment [Figure 2]. Stains such as Ziehl–Neelsen and periodic acid-Schiff diastase were negative. A chest X-ray was done to rule out sarcoidosis or other systemic abnormalities. Based on the clinical and histopathological findings, the diagnosis of granulomatous reaction to the red tattoo pigments was confirmed. The patient was started on intralesional triamcinolone acetonide injections at a dose of 40 mg/ml every 3 weeks. Following three treatment sessions, complete resolution of the lesions with mild hypopigmentation around the lesions was observed [Figure 1b].Figure 1: (a) Multiple, shiny, erythematous, nontender papules and plaques over the right forearm restricted to the red tattoo portions. (b) Complete resolution of the lesions with mild hypopigmentation around the lesions after the 3rd injection of weekly intralesional steroidFigure 2: Epidermal hyperplasia with dermal fibrosis and lymphohistiocytic, nonsarcoid, granulomatous infiltrate (blue arrow) surrounding the red tattoo pigment (red arrow)Tattoo reactions can be classified into acute inflammatory reactions, such as contact dermatitis and allergic contact dermatitis, as well as eczematous reactions. In addition, chronic conditions include granulomatous, lichenoid, and pseudolymphomatous types of reactions.[3] Other histological reactions that have been rarely reported are scleroderma or morphea-like, sarcoidal, and pseudoepitheliomatous hyperplasia. Lichenoid, granulomatous, and sarcoidal reactions are less common than eczematous reactions. Recently, a perforating granulomatous reaction to tattoo pigment has also been reported.[4] The acute inflammatory reaction usually occurs within 2–3 weeks after getting a tattoo, presenting as an acute aseptic inflammatory response with symptoms such as redness, skin hardening, and a swollen “peau d’orange” appearance. Allergic reactions in the form of type I and III hypersensitivity reactions to tattoo pigment are caused by the release of chemical mediators, such as histamine and prostaglandins. On histopathology, eosinophilic cells can be found. Granulomatous, lichenoid, and pseudolymphomatous types usually occur months to years after the tattoo is done. Histologically, in granulomatous reactions, there are well-defined epithelioid granulomas in close association with pigment. Lichenoid reaction is composed of a lymphocytic T-cell infiltrate. Pseudolymphomatous reaction shows a similar clinical aspect to cutaneous B-cell lymphoma, but different patterns can be found in histologic analysis. For example, there is predominant involvement of the upper dermis compared with the lower dermis in the cutaneous lymphoma, and lymphocytes are polyclonal in the pseudolymphoma reaction upon immunohistochemical analysis.[3] Cutaneous hypersensitivity reactions are most commonly associated with red (mercuric sulfide) tattoos; similar reactions have also been documented with other pigments, including yellow (cadmium sulfide), brown (iron oxide), blue (cobalt), purple (manganese), green (chromium), and black (carbon) tattoos.[4] The allergen is in the midreticular dermis, making treatment difficult for red tattoo reactions. In milder cases, topical, oral, and/or intralesional steroids, as well as oral antihistamines, may be considered a first-line treatment.[3] Intralesional steroid is a simple, less time-consuming, and cost-effective technique. However, clinical improvement is often temporary with a high chance of recurrence, and higher dosages can lead to epidermal and dermal atrophy and telangiectasias.[5] Oral or topical allopurinol, an inhibitor of xanthine oxidase, has been documented as an efficacious alternative treatment for sarcoidal and granulomatous reactions.[3] Destructive methods such as cryotherapy, radiofrequency ablation, excision, dermabrasion, and laser ablation are available alternatives. Q-switched laser is contraindicated for managing such allergic reactions due to the potential for an inflammatory response that could exacerbate the reaction.[3] With tattooing gaining popularity, awareness of such reactions is important. Our case demonstrates the potential of intralesional triamcinolone acetonide as an effective treatment with minimal side effects. However, as this approach is still experimental, further studies are needed to evaluate its efficacy, optimal dosing, and recurrence rates. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Authors’ contributions Literature search: BK. Data acquisition: SJ. Manuscript preparation: SK. Manuscript editing: JM. Manuscript review: SJ. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.