Histopathological evaluation of cutaneous reactions to tattoos: Study at a tertiary care center

Abstract

Background Tattooing has been around for many years and is becoming an increasingly common fashion trend. As there are often few regulatory laws regarding the practice, an increase in the incidence of cutaneous reactions to tattoo inks is noted. These include allergic reactions, granulomatous dermatitis, infections, lichenoid dermatoses, and sometimes malignancy. The present study examines the histopathological changes seen in patients with cutaneous reactions to tattoo ink. Method A prospective observational study was conducted over 18 months in the dermatology clinic of a tertiary care center in western India. The study population included 22 patients with cutaneous reactions over the tattoos. Punch biopsy specimens were sent to study the pattern of histopathological response. Results All 22 patients studied were between the ages of 17 and 35 years. The mean duration of development of reaction was 8.1 months. Most of the reactions were seen in black ink tattoos performed by amateurs. Perivascular and spongiotic dermatitis suggestive of allergic response was the most common feature on histopathology. Granulomatous response and lichenoid response were seen in five and three biopsies, respectively. Conclusion Legalization is needed for this practice to prevent tattoo reactions. Histopathological evaluation is important as tattoo reactions may be associated with skin infections and malignancies.

Clinical and Pathological Features of Persistent Decorative Tattoo Reactions

“…Persistent reactions to decorative tattoos are a large and heterogeneous group of complications characterised by a variable latency period from tattooing to the beginning of clinical manifestations. [ 3 4 7 ] In our series, intervals ranged from 2 weeks to 10 years and once established, they were persistent without significant clinical fluctuations. The reason for latency is unknown, but it could be related to the local transformation of ink components or haptenisation, forming neoantigens recognised by immune cells which trigger a cytotoxic response.…”

“…[ 4 5 7 9 ] It has been described as indistinguishable from lichen planus but in our cases, the inflammation extends much deeper, involving the reticular dermis, is more polymorphic and shows perivascular arrangement at least focally, features not present in conventional lichen planus. The interpretation of this interface reaction is not clear: Initially considered allergic,[ 4 9 ] the presence of apoptotic keratinocytes and CD8 predominant response could suggest a cytotoxic mechanism. [ 7 ] Only a subset of patients develops adverse reactions involving the same color in other tattoos, which could be expectable if the allergy was the mechanism involved.…”

“…We have found interface lichenoid dermatitis as the most usual inflammatory reaction pattern, a common but not constant feature in previous papers. [ 4 5 7 9 ] It has been described as indistinguishable from lichen planus but in our cases, the inflammation extends much deeper, involving the reticular dermis, is more polymorphic and shows perivascular arrangement at least focally, features not present in conventional lichen planus. The interpretation of this interface reaction is not clear: Initially considered allergic,[ 4 9 ] the presence of apoptotic keratinocytes and CD8 predominant response could suggest a cytotoxic mechanism.…”

“…[ 7 ] Only a subset of patients develops adverse reactions involving the same color in other tattoos, which could be expectable if the allergy was the mechanism involved. Moreover, eosinophils are not conspicuous in most cases[ 4 7 ] which is unexpected in allergic cutaneous reactions.…”

“…Hypersensitivity reactions, usually reported in association to red ink, are the most common type, while black is considered responsible for most non-allergic reactions. [ 1 2 3 4 ] Histopathologically, lichenoid and granulomatous reactions or non-specific inflammation have been described as the most frequent patterns, but the clinical and pathological correlation is not easily assessed. [ 2 5 6 ]…”