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29 year old incarcerated man presents with an extremely pruritic arm. The pruritus has caused extensive excoriations with subsequent ulcerations. Wound cultures and biopsies with special stains fail to identify an infectious etiology. Pathology does show granulomas and inflammation and “foreign substance”.
What is your diagnosis?
Diagnosis:
Allergy to tattoo ink pigment.
The most challenging issue is how to treat this patient. I contacted several colleagues and here is a list of their opinions:
A:
Is it just to one of the ink colors? I have had people get granulomatous reactions to red in particular. Some have been very severe - painful and ulcerating. Because there is foreign material I always had assumed it has to be removed somehow - laser or excision. But several of my patients who I have treated with IL kenalog and topical steroids eventually developed a tolerance to the tattoo pigment and eventually the reaction resolved completelyu without needing to continue any more treatment. Over a period of one or two years they became tolerant as I treated them symptomatically with the steroids. I had one lady - dark skin that had a severe painful large plaque granulomatous on the flexor wrist. It improved with IL kenalog and antibiotics but she grew frustrated. I sent her to a plastic surgeon who decided to cut it out as a staged procedure. He cut out half of it which fixed that half but the other half stayed inflamed and painful. She was schedule to have the other half cut out in like 6 months. but by the time that appointment came around the unexcised half completely resolved without any scarring. The untreated half looked completely normal compared to the nasty surgical scar that was excised.
So I would say be conservative and tell the patient that the body may develop a tolerance to the ink tattoo but it could take up to a couple of years.
B:
Staged excision; or you can do a ton of small shave removals of the affected areas - that's probably the way that I'd go. He's going to keloid. It's going to look horrible - but I don't think he cares. I bet he'll be thrilled to have it stop itching. Had a similar case of a guy with lichenoid rash to red tattoo pigment on his leg. Did about 20 shave removals of the affected areas. Healed pretty good. No recurrence 1 year post.
C:
I agree, use qswitched yag at 532 to get pigment out faster. May need to cover with prednisone or Kenalog when treating. Does exacerbate local reaction.
Have not seen systemic problems, although a few have been reported. I treat at two week intervals in darker skin types before repigmentation occurs
for deeper penetration. the picosecond 532,1064 will be out soon...
D:
Agree. Poor guy! the only other thing is an atypical mycobacteria. We had a series of cases of this at Mayo and we wrote it up. But this really does truly look like what you say- allergy to pigment.
E:
IL Kenalog or Prednisone to get the reaction under control and Biafine Emulsion (don't let them substitute for generic) as often as possible during the day for wound healing, followed by laser to remove the tattoo ink that he's allergic to but it seems as though his body has already taken care of that.
These comments are all very insightful and helpful.
In this case we will use metrogel and biafine emulsion for infection control and to promote wound heling.IL Kenalog, PRN for allergic reaction/pruritic control. When he is released in 9 months, if it is still problematic, we will consider micro punches or shaves and/or laser tattoo removal.
If any others have suggestions, I’d love to hear it.
Thanks!
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