A 26-year-old Hispanic woman presents with a complaint of an itchy and disfiguring rash that developed from several tattoos that were inked 3 months earlier. The patient notes that she has no prior history of skin rashes including eczema, psoriasis, and contact dermatitis. On physical examination, only the red-pigmented areas of the tattoos appear to be affected. Firm, well-demarcated hyperpigmented plaques are noted.
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The number of Americans receiving tattoos continues to increase. According to an Ipsos poll, the number of Americans with at least 1 tattoo grew by nearly 50% between 2012 and 2019.1 Interesting statistics regarding tattoos include2:
- 15% of men and 13% of women in the US have tattoos.
- 36% of US citizens aged 18-29 years have at least 1 tattoo.
- 30% of US college graduates have tattoos.
- 72% of inked adults have tattoos that are hidden by their clothing.
Complications from tattooing are divided into several categories such as infectious, reactive, and allergic.3 Staphylococcus, streptococcus, and pseudomonal bacteria can be introduced into treated areas during the tattoo process or healing phase and cause infections. Acute bacterial infections usually present as red, swollen, and painful areas. Reactive processes triggered by tattooing include sarcoid and keloid development. Tattoo-associated sarcoid may be either localized or systemic and is confirmed by biopsy.4 Additional reactive processes include cutaneous pseudolymphoma and inducement of the Koebner response in patients with psoriasis.5
Allergic reactions to red tattoo ink are not uncommon and are believed to be induced by a delayed type IV allergic reaction.6 In addition to unacceptable cosmesis, affected areas may itch or cause pain. Conservative treatment consists of mild to ultrapotent topical steroids and intralesional injections of triamcinolone. Often adequate control can only be achieved by pigment removal accomplished by laser or surgical excision. Patients should be instructed to avoid future tattoos with the inciting color.
Lawrence Schiffman, DO, is the founder and director of Miami Skin Dr in Doral, Florida.
Stephen Schleicher, MD, is director of the DermDox Dermatology Centers, associate professor of medicine at Geisinger Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.
1. More Americans have tattoos today than 7 years ago. News release. Ipsos. August 29, 2019. Accessed August 2, 2023. https://www.ipsos.com/en-us/news-polls/more-americans-have-tattoos-today
2. Zuckerman A. 38 Tatto statistics: 2020/2021 industry, trends & demographics. May 12, 2020. Accessed August 2, 2023. https://comparecamp.com/tattoo-statistics/
3. Serup J, Carlsen KH, Sepehri M. Tattoo complaints and complications: diagnosis and clinical spectrum. Curr Probl Dermatol. 2015;48:48-60. doi:10.1159/000369645.
4. Kluger N. Sarcoidosis on tattoos: a review of the literature from 1939 to 2011. Sarcoidosis Vasc Diffuse Lung Dis. 2013;30(2):86-102.
5. Weiß KT, Schreiver I, Siewert K, et al. Tattoos ― more than just colored skin? Searching for tattoo allergens. J Dtsch Dermatol Ges. 2021;19(5):657-669. doi:10.1111/ddg.14436
6. van der Bent SAS, van Doorn MBA. Treatment of a refractory allergic reaction to a red tattoo on the lips with methotrexate and Q-switched Nd-Yag laser. JAAD Case Rep. 2022;21:109-111. doi:10.1016/j.jdcr.2022.01.004.