Beyond aesthetics: Granulomatous complications of tattoos

Tattoo granulomas represent a chronic inflammatory response to exogenous pigments and can clinically mimic infectious and non-infectious dermatoses. We present a case series of five patients with tattoo-associated granulomatous reactions, highlighting the spectrum of histopathological findings, including foreign body granuloma and features consistent with lupus vulgaris. Clinically, patients presented with erythematous to violaceous papules and plaques confined to tattooed areas, with variable latency periods. Histopathology revealed non-caseating granulomas with pigment-laden macrophages in three cases, consistent with foreign body granuloma, while two cases demonstrated epithelioid granulomas with caseation and associated features suggestive of cutaneous tuberculosis. Special stains and clinicopathological correlation were essential for accurate diagnosis. Therapeutic approaches varied from intralesional corticosteroids to anti-tubercular therapy, depending on etiology. This series emphasizes the importance of considering infectious causes, particularly in endemic regions, and highlights the need for histological evaluation in atypical tattoo reactions.