Successful Medical Treatment of a Severe Reaction to Red Tattoo Pigment

A 29-year-old woman presented to dermatology clinic with an allergic reaction to a tattoo she had received two weeks previously. She was otherwise in excellent health, took no other medications, and had no history of allergies. This was her first tattoo and she expressed a specific desire to preserve the cosmetic integrity for personal reasons. On physical exam, there was focal erythema and ulceration in the areas of her tattoo with red pigment, and superficial honey-colored crusting indicative of co-infection (Figure 1). Review of systems was negative for any signs of extracutaneous allergic reaction. We educated the patient that based upon her physical exam findings, her skin reaction represented an allergy to tattoo ink, and offered medical management to preserve the cosmetic appearance of the tattoo. We also provided clear guidance to consider avoiding future tattoos, as the allergic reaction to a future tattoo may be worse than the first – locally with regards to her skin, and with a potential for systemic allergic symptoms.

She was treated with twice daily application of mupirocin ointment for one week, at which point the superficial infection resolved. The affected areas were then treated with twice daily application of white petrolatum to promote wound healing and 0.1% triamcinolone ointment to decrease the allergic reaction to the tattoo dye and decrease associated inflammation. After three months, the ulcers had fully re-epithelialized, and the patient was pleased she was able to preserve the integrity of her tattoo (Figure 2).

Tattoo allergies typically present with an eczematous eruption that may include focal edema, pruritus, papules, and/or nodules.¹ In rare instances, ulceration and co-infection can occur. This case is being presented to provide an effective treatment algorithm for managing allergic tattoo reactions with ulceration and co-infection, while preserving the aesthetic integrity of the tattoo.

Hypersensitivity reactions to tattoos occur most frequently in areas of red pigment.² Mercury contained in red mercuric sulphide (cinnabar) has been identified as the causative agent associated with allergic reactions to red tattoos.³ However, even when alternatives to mercury are used, sensitivity reactions may still occur. Other red dye pigments implicated in these reactions include sienna/red ochre (ferric hydrate), cadmium red (cadmium selenide), and organic vegetable dyes (sandalwood, brazilwood).² Since little regulation of tattoo ink composition exists, a single color can contain varying amounts of dyes and metals.⁴ X-ray microanalysis has shown red tattoo pigment to include a number of metallic elements including aluminum, iron, calcium, titanium, silicon, mercury, and cadmium, all of which may cause allergic reactions.⁵

Patch testing to red pigments and their individual metallic components is often unreliable.² This may be due to the fact that pigments increasingly contain synthetic dyes that are not available for allergy diagnosis.⁶ It has also been hypothesized that since the pigments are deposited with a needle directly into the dermis, they are presented only to local dendritic cells, and not to the epidermal Langerhans cells, which are the cells that react to patch testing.⁶

No consistently effective treatment for tattoo allergies has been reported. Conservative treatment options include topical, oral, and/or intralesional steroids, oral antihistamines, and protection from light. When these fail, destructive methods such as cryotherapy, electrosurgery, surgical excision, or laser (CO₂ laser, Q-switched lasers) have been utilized, with