This supplementary information is presented as submitted by the corresponding author. It has not been copy-edited by NTvG.
Tattooing involves the introduction of exogenous pigment into the dermis. Worldwide, tattoos are one of the most popular forms of permanent body art. In the Netherlands, 8-10% of the population older than 12 years old has a tattoo. A wide variety of cutaneous adverse effects can occur in tattoos, these can cause serious symptoms. However, recognition and appropriate knowledge of diagnosis and treatment is still frequently insufficient in many medical practitioners.
The first case concerns a 57-year-old female, who developed an itching swelling in the red part of a tattoo on the left arm. Histology of a punch biopsy showed a pseudolymphomatous reaction. This plaque-like allergic reaction was successfully treated with intralesional injection of corticosteroids.
The second case concerns a 50-year-old female, who developed an extensive painful ulceration in the red part of a tattoo on the lateral part of her right ankle. Treatment included compression bandaging, adequate wound care and analgesia. The third case involved a 57-year-old male, who visited the department of dermatology because of an itching skin lesion in a black tattoo. Histology of a punch biopsy revealed a nodular basal cell carcinoma. Surgical excision was performed. The fourth case concerns a 27-year-old male with psoriasis vulgaris. Two weeks before he got a tattoo on his lower left arm, causing a local exacerbation of psoriasis in the tattoo.
Here we described four cases of cutaneous adverse reactions to tattoos. Allergic reactions in tattoos can present in a wide variety of clinical and histological patterns. The symptoms are often chronic itch and can appear weeks, months or years after placing the tattoo. Allergic reactions are uniformly manifested in one particular colour. Clinically, the reactions can present in a plaque-like, hyperkeratotic or rarely ulcerative or generalised reaction. In spite of changes to the compounds in tattoo inks, allergic reactions are still mostly observed to red ink. Treatment options are topical corticosteroids, intralesional injection of corticosteroids, laser treatment or dermatome shaving.
Despite strict hygiene protocols, infections remain the most frequently occurring adverse event. Autoimmune and other inflammatory skin diseases can be localized in tattoos, such as lichen planus, psoriasis, lupus erythematosus, vitiligo and sarcoidosis. The induction of these skin disorders can partly be explained by the trauma caused by the process of tattooing: the Koebner phenomenon. The number of reported skin cancers in tattoos is low. As yet, the association between skin cancer and tattoo has to be considered as coincidental.