This 51-year-old African-American woman with hypertension was evaluated for 3 nodules which developed within a tattoo that had been placed 10 years previously. Over the last few months, she had also noted the development of papular lesions on her nose and right cheek. Patient was concurrently being worked up for chronic bronchitis and shortness of breath.Lupus pernio presents as violaceous or red-brown, papules, nodules or plaque-like lesions with a predilection for "cold-sensitive areas, such as the nose, ears, cheeks, and fingers. One characteristic of lupus pernio is a beaded appearance along the nasal rim. It is most commonly seen in middle-aged African American women. Cystic lesions of the distal phalanges are also seen more frequently in patients who have lupus pernio. Lupus pernio is associated with pulmonary sarcoidosis in up to 77 percent of cases, and it is also strongly associated with involvement of the upper respiratory tract as wekk as uveitis. The cutaneous, pulmonary, and upper respiratory tract disease in patients with lupus pernio tends to be chronic. Untreated lesions may lead to significant disfigurement.
This case demonstrates cutaneous lesions arising within a tattoo. As tattoos have become increasingly popular in todays’s society, dermatologists should be aware of the different tattoo-associated dermopathies.
Allergic and granulomatous reactions arising within a tattoo are not rare. Hypersensitivity (presumed type IV) to components of the red dye used in tattoos is well documented, and the most frequent cause has been mercuric sulfide (cinnabar and vermilion). Allergies to other metallic salts include allergy to cobalt blue, chrome green and cadmium yellow. Reactions to henna in temporary tattoos have also been reported. These reactions make take the form of local contact dermatitis, generalized eczema or lichenoid lesions. Urticaria has also been reported in a tattooed patient due to hypersensitivity to the cobalt chloride contained in the blue ink. Granulomatous lesions usually represent a local hypersensitivity reaction to tattoo pigments, especially red, but they may also be a manifestation of systemic sarcoidosis. Sarcoidosis, an idiopathic granulomatous disease with many cutaneous manifestations, has a known predilection for scars and areas of previous trauma such as tattoos.
Infections from tattoo inoculation that have been reported include tuberculosis, verruca, zygomycosis, leprosy, hepatitis, sporotrichosis, molloscum contagiosum, herpes simplex and vaccinia.
Skin conditions that koebnerize such as psoriasis may certainly occur within a tattoo.
Finally, coincidental lesions may occur within a tattoo. Among those reported include B cell lymphoma, pseudolymphoma, melanoma, basal cell carcinoma, squamous cell carcinoma and non-Hodgkin’s lymphoma.
References:
1. Collins P, Evans AT, Gray W, Levison DA. Pulmonary sarcoidosis presenting as a granulomatous tattoo reaction. Br J Dermatol. 1994 May;130(5):658-62
2. Ghorpade A. Inoculation (tattoo) leprosy: a report of 31 cases.
J Eur Acad Dermatol Venereol. 2002 Sep;16(5):494-9.
3. Jacob CI. Tattoo-associated dermatoses: a case report and review of the literature. Dermatol Surg. 2002 Oct;28(10):962-5. Review.
4. Kahofer P, El Shabrawi-Caelen L, Horn M, Kern T, Smolle J. Pseudolymphoma occurring in a tattoo. Eur J Dermatol. 2003 Mar-Apr;13(2):209-12.
5. Papageorgiou PP, Hongcharu W, Chu AC. Systemic sarcoidosis presenting with multiple tattoo granulomas and an extra-tattoo cutaneous granuloma. J Eur Acad Dermatol Venereol. 1999 Jan;12(1):51-3.
6. Verdich J. Granulomatous reaction in a red tattoo. Acta Derm Venereol. 1981;61(2):176-7.
Description
A biopsy of a nodule on the tattoo showed a sarcoidal granulomatous dermatitis
