Successful Treatment of a Lichenoid-Like Granulomatous Reaction to Purple Tattoo Pigment With Intralesional Kenalog

June 2015 | Volume 14 | Issue 6 | Case Reports | 638 | Copyright © June 2015

Stephanie Feldstein MDa and Jared Jagdeo MD MSb,c,d

aSchool of Medicine, University of California, San Diego, CA
bDepartment of Dermatology, University of California Davis, Sacramento, CA
cDermatology Service, Sacramento VA Medical Center, Mather, CA
dDepartment of Dermatology, State University of New York Downstate Medical Center, Brooklyn, NY

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patient’s reaction appeared to occur in areas of purple tattoo pigment, it is possible that red ink components were mixed into the purple ink and were the causative agent for his reaction.
In contrast to red tattoo reactions, reactions to purple tattoo pigment are extremely rare and have been reported in less than a handful of cases. Purple tattoo ink is comprised of manganese ammonium pyrophosphate, diaxoazine/carbazole, and various aluminum salts.6 Of these components, manganese is thought to be the inciting agent in purple tattoo reactions.2 Similarly to our case, Schwartz et al described a granulomatous reaction occurring in purple tattoo pigment three weeks after tattoo application.7 Litak et al described a generalized lichenoid reaction to purple tattoo ink, which occurred at sites not involving the tattoo.2 Balfour et al and Cruz et al both independently described delayed onset of pseudoepitheliomatous hyperplasia occurring in the purple pigment of tattoos within a year of their application.13,14
To our knowledge, no consistently effective treatment for lichenoid or granulomatous tattoo reactions has been described in the medical literature. Topical steroids have been reported to have a variable response; while some cases cite improvement after topical steroid use,3,15,16 most report these agents as having little-to-no effect.3,17-19 We also found that topical fluocinonide 0.05% ointment was unable to effectively resolve our patient’s skin lesions. When topical therapies fail, Q-switched Nd:Yag and Er:Yag lasers18-19 and surgical excision2,20 have been used to treat tattoo reactions, resulting in partial or complete tattoo destruction.
Only four reports document the use of ILK for lichenoid tattoo reactions. In three cases, the lesions failed to resolve,2-3,18 and in one case, ILK injections were successful in treating the lichenoid reaction.14 ILK injections have successfully induced resolution of a granulomatous tattoo reaction in a previous case report.21 For our patient, one treatment with ILK injections led to resolution of his lesions.