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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 26  |  Issue : 4  |  Page : 244-246

Multiple pigmented macules as a sequel of cosmetic lip micro-pigmentation: New clinical presentation of tattoo reactions


1 Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Dermatology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
3 Student Research Committee, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
4 Student Research Committee, School of Pharmacy, Isfahan University of Medical Sciences, Isfahan, Iran
5 Student Research Committee, Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Date of Web Publication4-Oct-2019

Correspondence Address:
Dr. Ali Saffaei
Student Research Committee, Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Niayesh Highway, Valiasr Avenue, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_88_19

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  Abstract 


Cosmetic tattooing using micro-pigmentation has gained popularity in recent years. Tattoos can cause a broad range of clinical and psychosocial problems. Several medical complications may arise after tattooing. A 35-year-old female was referred with an 8-week history of grey-to-smoky hyperpigmentation of permanent makeup of lips and lip lines. Histopathological examination revealed lichenoid lymphocytic infiltrations in the dermis. Clinical and histopathological findings were compatible with the diagnosis of multiple pigmented macules as a sequel of cosmetic lip micro-pigmentation. Here, we report the first case of lichenoid-type tattoo reactions with new presentation as multiple asymptomatic pigmented macules after lip tattooing. The current report emphasises the requirement of a skin biopsy of all tattoo reactions. Considering the new component in the tattoo material, a dermatologist should be aware of the new clinical presentation of tattoo reactions that may occur.

Keywords: Histopathological examination, lichenoid reactions, micro-pigmentation, tattoo


How to cite this article:
Abtahi-Naeini B, Shahmoradi Z, Hadian M, Niknami E, Saffaei A. Multiple pigmented macules as a sequel of cosmetic lip micro-pigmentation: New clinical presentation of tattoo reactions. Niger Postgrad Med J 2019;26:244-6

How to cite this URL:
Abtahi-Naeini B, Shahmoradi Z, Hadian M, Niknami E, Saffaei A. Multiple pigmented macules as a sequel of cosmetic lip micro-pigmentation: New clinical presentation of tattoo reactions. Niger Postgrad Med J [serial online] 2019 [cited 2019 Nov 18];26:244-6. Available from: http://www.npmj.org/text.asp?2019/26/4/244/268600




  Introduction Top


In recent years, cosmetic tattooing by micro-pigmentation is widely utilised instead of temporary makeups, particularly in young people.[1] The growing popularity of tattooing has led to the development of several new tattoo colourants; however, little data are available on the toxicological risks and adverse events of the ingredients used.[1],[2] Tattoos can cause a broad range of clinical and psychosocial problems. These complications include tattoo-related infections (e.g., viral hepatitis, human immunodeficiency virus and mycobacterial infections), eczematous, granulomatous, lichenoid patterns, koebnerization of existing dermatoses, pseudo-epitheliomatous hyperplasia and development of malignancy.[3] A few of these tattoo reactions may lead to cutaneous or systemic disease, whereas others may substantially overlap with other inflammatory or malignant lesions, which can result in misdiagnosis and mismanagement.[4] A skin biopsy is recommended for all tattoo reactions to avoid systemic implications.[3] Previous studies have reported lichenoid reaction pattern in tattoo,[5] but we report a case of lichenoid tattoo reactions with new rare presentation as multiple pigmented macules.


  Case Report Top


A 35-year-old female received permanent makeup (red-pink) of lips and lip lines by micro-pigmentation (a low-cost product with no information on the label, claimed to be originated from India) by a nonmedical professional. Unwanted hyperpigmentation, associated with mild pruritus, occurred on her upper lip line, 5 weeks after a single session of tattooing. An attempt by the same nonmedical professional to rectify the initial unfavourable outcome, by tattooing with light red pigments to camouflage the previous pigment area, resulted in the development of new hyperpigmentation 2 weeks after the second session of micro-pigmentation. About 8 weeks after the initial procedure, she was referred to a dermatologist for consultation at Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran. Clinical examination showed multiple areas of grey-to-smoky hyperpigmentation on the lips. In addition, a streak-like hyperpigmentation was observed on her lip along the upper border of the upper lip [Figure 1]. There was no recent use of any medications by the patient. The histopathological sections of a biopsy from pigmented lip macule were notable lichenoid lymphocytic infiltrations. Mild acanthosis, basal vacuolar degeneration and prominent band-like infiltration were notable [Figure 2]. Further, higher magnification of band-like infiltration represented lymphocytic infiltration and degenerating necrotic keratinocytes associated with scattered eosinophils. With the clinical and histological features observed, a diagnosis of new presentation of lichenoid tattoo reactions following lip tattooing was made and possible treatment options were discussed with the patient. The patient was counselled on the need to avoid direct sun exposure. A satisfactory therapeutic outcome was achieved with 3 months of topical clobetasol propionate 0.05% cream and topical tacrolimus 0.1% cream [Figure 3].
Figure 1: Multiple dark pigmentation within red-inked lip

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Figure 2: Histopathological image showing the dominant lichenoid lymphocytic infiltrations without atypia changes. (a) Histopathological examination demonstrated mild acanthosis, basal vacuolar degeneration and prominent band-like infiltration (×40). (b) Higher magnification of band-like infiltration (arrow) represented lymphocytic infiltration and degenerating necrotic keratinocytes associated with scattered eosinophils (×100)

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Figure 3: The satisfactory outcome achieved after 3 months' therapy

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  Discussion Top


Tattoo colourants generally contain different materials that are injected into the skin. The main component in tattoo colourants is the colouring component, which can be categorised into two different groups. First, the amorphous carbon particles (carbon black) are present in black tattoos, while tattooists use the azo- and poly-cyclic pigments to generate almost all colours of the visible spectrum. As a result of their different chemical compositions, tattoo colourants comprise several ingredients, such as by-products and impurities. Tattooing of the colourants into skin triggers an intricate immune reaction, and this can pose additional health risks to the skin and other human organs.[6] The mixture of tattoo inks is unreliable, and in some products, no list of ingredients is provided.

Among the tattoo colourants, the red pigments are prone to cause more adverse reactions than the blue and green tattoos.[7] Nevertheless, tattooing is generally a single-dose exposure; the presence of exogenous elements in the dermis represents a uniquein vivo situation, where a considerable quantity of organic dyes and metallic salts are retained in the skin for long-time and are considered as permanent exposure for induced reaction.[8] In spite of the transition from mercury-based inks to other dyes and metals, reactions to red ink are frequent.[9] Moreover, a majority of lichenoid reactions likely occurs in red-coloured tattoos.[5],[10] Although the lichenoid tattoo reactions are reported as pruritic papules or plaques within tattooed skin,[3] few other lichenoid tattoo reactions such as cutaneous lupus erythematosus-like reactions [11] and generalised lichenoid reaction may be rare variant.[12] Pigmented macule reactions, as seen in the patient, may be a new variant of the lichenoid tattoo reactions, and to the best of our knowledge, these have been not previously reported. Identifying the reactions' causative ingredient has been difficult in tattoo reactions; however, nickel, mercury and cadmium in the red pigment have been implicated.[13]

From the findings in our study, it is highly recommended that skin biopsies of all tattoo reactions should be done and the dermatologist should be aware of the new clinical presentation of the tattoo reactions that may occur.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Laux P, Tralau T, Tentschert J, Blume A, Dahouk SA, Bäumler W, et al. Amedical-toxicological view of tattooing. Lancet 2016;387:395-402.  Back to cited text no. 1
    
2.
Khunger N, Molpariya A, Khunger A. Complications of tattoos and tattoo removal: Stop and think before you ink. J Cutan Aesthet Surg 2015;8:30-6.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Simunovic C, Shinohara MM. Complications of decorative tattoos: Recognition and management. Am J Clin Dermatol 2014;15:525-36.  Back to cited text no. 3
    
4.
Naeini FF, Pourazizi M, Abtahi-Naeini B, Saffaei A, Bagheri F. Looking beyond the cosmetic tattoo lesion near the eyebrow: Screening the lungs. J Postgrad Med 2017;63:132-4.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Garcovich S, Carbone T, Avitabile S, Nasorri F, Fucci N, Cavani A. Lichenoid red tattoo reaction: Histological and immunological perspectives. Eur J Dermatol 2012;22:93-6.  Back to cited text no. 5
    
6.
Bäumler W. Absorption, distribution, metabolism and excretion of tattoo colorants and ingredients in mouse and man: The known and the unknown. Curr Probl Dermatol 2015;48:176-84.  Back to cited text no. 6
    
7.
Vasold R, Engel E, König B, Landthaler M, Bäumler W. Health risks of tattoo colors. Anal Bioanal Chem 2008;391:9-13.  Back to cited text no. 7
    
8.
Serup J, Carlsen KH, Sepehri M. Tattoo complaints and complications: Diagnosis and clinical spectrum. Curr Probl Dermatol 2015;48:48-60.  Back to cited text no. 8
    
9.
Corazza M, Zampino MR, Montanari A, Pagnoni A, Virgili A. Lichenoid reaction from a permanent red tattoo: Has nickel a possible aetiologic role? Contact Dermatitis 2002;46:114-5.  Back to cited text no. 9
    
10.
Mortimer NJ, Chave TA, Johnston GA. Red tattoo reactions. Clin Exp Dermatol 2003;28:508-10.  Back to cited text no. 10
    
11.
La Placa M, Passarini B. Subacute cutaneous lupus erythematosus after a tattoo. Clin Exp Dermatol 2009;34:632-3.  Back to cited text no. 11
    
12.
Litak J, Ke MS, Gutierrez MA, Soriano T, Lask GP. Generalized lichenoid reaction from tattoo. Dermatol Surg 2007;33:736-40.  Back to cited text no. 12
    
13.
Serup J, Hutton Carlsen K. Patch test study of 90 patients with tattoo reactions: Negative outcome of allergy patch test to baseline batteries and culprit inks suggests allergen(s) are generated in the skin through haptenization. Contact Dermatitis 2014;71:255-63.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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