Systemic Allergic Reaction to Red Tattoo Ink Requiring Excision

W e present a case of a systemic allergic red tattoo reaction that required excision and skin grafting after failure of other therapies. Tattoos are associated with an increased risk of infection , eczema, psoriasis, hyperplasia, granulomatous reactions, and neoplasm, with red ink as the most common culprit for allergic reactions. Although artists have replaced dangerous mercury-based cinnabar dyes with organic red dyes, the latter are not risk free. A 48-year-old woman with a past medical history significant for rosacea, celiac disease, and migraines, as well as allergy to lanolin and sulfa, and no heavy metal allergy, was referred to our clinic after a reaction to a tattoo on the dorsum of the left foot. One month after the tattoo was completed, she reported that the red-pigmented areas became raised and pruritic, whereas the rest remained flat (Fig. 1). It is unknown what red dye was used for this tattoo. A biopsy from a red portion showed an exuberant lymphohistiocytic infiltrate with extensive cinnabar pigment deposition. One month after the initial reaction, the patient developed a widespread eruption on her trunk and extremities showing changes consistent with dermatitis on histopa-thology. Topical clobetasol (Cormax), intralesional ste-roids, and a single CO 2 laser treatment did not improve symptoms. After the rash spread to her face, she was given 3 courses of systemic corticosteroids, which improved but did not resolve her symptoms. Upon examination, the violet-colored areas were indu-rated; there was no evidence of the previous widespread dermatitis. The patient also demonstrated evidence for mild tinea pedis and her previously diagnosed rosacea, with scaling over the soles and pinpoint papules with ery-thema over the cheeks. Patch testing using the 80 allergen standard North American Screening Series, the patient's personal care products, and a select metal series was only positive for lanolin and negative for heavy metals found in tattoo dyes. The patient was referred for surgical excision as this was thought to be the best option for her persistent symptoms. Eight months after her initial reaction, she underwent a 6-cm excision with complex wound closure to preserve tattoo geometry. Two months later, another 15-cm excision removed the remaining induration. The wound was filled with a 15-× 6-cm full-thickness skin graft and with a 50-cm 2 rotation flap. Follow-up 1 week later showed a well-healed site with a complete take of the graft (Fig. 2). Her systemic symptoms also resolved. Although allergic reactions are …