Histopathologic Spectrum of Findings Associated With Tattoos: Multicenter Study Series of 230 Cases

Abstract

Importance: Reactions to tattoo may simulate common dermatosis or skin neoplasms. Histopathology allows diagnosis and helps determining the level and degree of inflammation associated, consequently orientating treatment.Objective: To describe the histological features found in biopsies of cutaneous reactions to tattoo.Design: This study was designed as a multicenter case series.Setting: All consecutive histopathological samples of tattoos referred from 1992 to 2019 to the Hospital General de Catalunya, Hospital Germans Trias i Pujol, and a private practice, all in Barcelona, Spain, and from the Kempf und Pfaltz Histologische Diagnostik in Zurich, Switzerland were retrieved from the files.Participants and Exposure: The inclusion criteria were all cosmetic/permanent makeup, artistic/professional, and traumatic tattoos associated with either inflammatory reactions alone and/or with tumors and/or infections. Exclusion criteria were cases without any associated pathologic finding in the place of the ink, amalgam tattoos, and medical or temporary tattoos. Main Outcomes and Measures:In all patients, clinical features (age, sex, location, tattoo color, and presentation) were recorded. Histological features evaluated included ink color, associated tumors or infections, and inflammatory reaction pattern. Inflammation was graded in low to moderate or severe.Results: From 477 biopsies diagnosed as tattoos, 230 cases from 226 patients met the inclusion criteria. Samples corresponded to 107 male and 120 female subjects and 3 of unknown gender. Median age was 39 years (ranging from 9 to 84 years). Fifty-three samples were referred from centers in Spain and 177 from the center in Switzerland. The series was analyzed in 2 parts: tattoos associated only with inflammatory reactions (117/230) and tattoos associated with tumors or infections (113/230). The most common form of inflammatory pattern associated with tattoo was the fibrosing reaction (79/117, 68%), followed by granulomatous reaction (56/117, 48%), lichenoid reaction (33/117, 28%), epithelial hyperplasia (28/117, 24%), pseudolymphoma (27/ 117, 23%) and spongiotic reaction (27/117, 23%). Combined features of 2 or more types of inflammatory patterns were seen in 64% cases.Conclusions and Relevance: Our series confirms that cutaneous reactions to tattoos are polymorphous. Inflammation tends to present with combined patterns. Infections are tending to decline, and pathologic findings are not specific to ink color or clinical features.

Wells Syndrome-Like Histologic Pattern Caused by a Permanent Tattoo

“…A recent retrospective study by Maya et al 2 reviewed 230 tattoo skin specimens and found that common inflammatory patterns associated with tattoos were fibrosing reactions (79/117, 68%), followed by granulomatous reactions (56/117, 48%), lichenoid reactions (33/117, 28%), epithelial hyperplasia (28/117, 24%), pseudolymphoma (27/117, 23%), and spongiotic reactions (27/117, 23%). Combined features of 2 or more types of inflammatory patterns were seen in 64% cases.…”

“…Tattoo reactions have become more common because tattoos gain visibility and popularity globally. 1,2 A variety of inflammatory patterns have been described in association with tattoos-including fibrosing, granulomatous, lichenoid, pseudolymphomatous, and spongiotic patterns. 2 Some tattoos have been associated with allergic hypersensitivity reactions, although the presence of eosinophils is not that common.…”

Hypersensitivity to permanent tattoos: Literature summary and comprehensive review of patch tested tattoo patients 1997–2022

“…37 Histologically, tattoo complications are characterized by severe inflammation with a high share of lymphocytes, histiocytes and macrophages. [38][39][40] Most frequently observed patterns were mixed and included fibrosis, interface activity and major signs of type IV reactions like spongiosis and acanthosis. 38,[40][41][42] Severe allergic reactions do usually not respond to medical treatment with corticosteroids and often need complete removal of the colorant from the skin, which can be achieved by surgical or CO 2 -laser removal.…”

“…[38][39][40] Most frequently observed patterns were mixed and included fibrosis, interface activity and major signs of type IV reactions like spongiosis and acanthosis. 38,[40][41][42] Severe allergic reactions do usually not respond to medical treatment with corticosteroids and often need complete removal of the colorant from the skin, which can be achieved by surgical or CO 2 -laser removal. 43,44 In a small German case series, even superficial removal of affected tattoos was sufficient to provide cure and aesthetically acceptable results in three patients.…”

“…Eczematous ACD reactions (Figure 2) are characterized by papules and infiltration, are not necessarily restricted to the tattoo area or maybe generalized, and were rarely reported 37 . Histologically, tattoo complications are characterized by severe inflammation with a high share of lymphocytes, histiocytes and macrophages 38–40 . Most frequently observed patterns were mixed and included fibrosis, interface activity and major signs of type IV reactions like spongiosis and acanthosis 38,40–42 .…”