Pandemic Tattoo Reactions – A Scenario on the Surge; A Series of 30 Cases

Abstract

Since ancient era, tattooing has been very popular, but in the recent times, it has been perceived as a form of art and is quite popular for cosmetic purposes. During the COVID pandemic, while most businesses were struggling, the tattoo industry flourished. This in turn led to an increase in tattooing practices causing a surge in tattoo site complications as well. We hereby present a series of 30 cases of tattoo site reactions which we have encountered as a direct result of tattooing during the pandemic.

Tattooing is a process of inoculating an exogenous pigment in the dermis in order to create a particular design. It has been practiced in India since the ancient era with tremendous religious and spiritual significance; but in the recent era, tattoos have been a form of art and are quite popular for cosmetic purposes. Coronavirus disease 2019 (COVID-19) has had and also continues to have a huge impact on the lifestyle of the general population causing massive mental distress due to loss of loved ones, leading to a ‘You only live once’ attitude.

While most businesses were struggling during the pandemic, the tattoo industry flourished. The increase in tattooing practice has led to a surge in tattoo site complications as well. We hereby present a series of 30 cases of tattoo site reactions, which includes both infective and non-infective complications which we have encountered between July 2020 and June 2023 and were a direct result of tattooing during the pandemic.

Case Series

We came across a series of tattoo-related reactions during the pandemic period and even post pandemically. All the required investigations such as potassium hydroxide (KOH) mount for fungal elements, punch biopsy for histopathology, and slit skin smear for acid fast bacilli were done to reach a definite diagnosis. A brief description of cases are mentioned in Tables 1 and 2, and patient demographic details are mentioned in Table 3.

Table 1.

Infective tattoo site reactions; brief description

Infective causes	No. of cases seen	Tattoo done by	Ink used	Chief complaints	Duration	Investigations done
Hansen’s disease	1	Amateur	Black	Hypopigmented hypoesthetic patch	5 months	Slit skin smear Punch biopsy
Tuberculosis verrucosa cutis	5	Amateur/professional	Black	Well-defined hyperkeratotic indurated plaque over the tattoo	3–6 months	Punch biopsy
Tinea corporis	8	Professional	Black	Erythematous annular plaque limited to the tattoo site	2–4 months	KOH mount for fungal elements

Table 2.

Non-infective tattoo site reactions; brief description

Non-infective causes	No. of cases seen	Tattoo done by	Ink used	Chief complaints	Duration	Investigations done
Irritant contact dermatitis	1	Professional	Black	Burning sensation over tattoo site	3 days	Clinical diagnosis
Hypertrophic scar	4	Professional	Black	Indurated plaques over the tattoo site	1 year	Punch biopsy
Vitiligo over a tattoo	1	Professional	Black	Depigmented patch over the tattoo	5 months	Clinical diagnosis
Pseudolymphoma	3	Professional	Red and black	Well-defined indurated linear plaques over a tattoo	2 months	Punch biopsy
Lichenoid reaction	6	Professional	Red and black	Flat topped papules over the tattoo	8 months	Punch biopsy
Sarcoidosis	1	Professional	Black	Indurated plaques over the tattoo	6 months	Punch biopsy

Table 3.

Patient demographic details

Age	Gender	Tattoo artist	Reason for getting inked as per each patient
20	M	Amateur	Marker of identity
20	M	Amateur	Survivor of covid infection
21	M	Amateur	Loss of loved one to covid
23	M	Amateur	Loss of loved one to covid
24	M	Professional	Always wanted to get tattooed
25	M	Professional	Body adornment
25	M	Professional	Loss of loved one to covid
25	M	Professional	Loss of loved one to covid
26	M	Professional	Survivor of covid infection
27	M	Professional	Always wanted to get tattooed
27	M	Professional	Body adornment
27	M	Professional	Survivor of covid infection
28	M	Professional	Survivor of covid infection
28	M	Professional	Loss of loved one to covid
29	M	Professional	Marker of identity
29	M	Professional	Always wanted to get tattooed
30	M	Professional	Loss of loved one to covid
37	M	Professional	Loss of loved one to covid
25	F	Professional	Survivor of covid infection
27	F	Professional	Loss of loved one to covid
28	F	Professional	Body adornment
29	F	Professional	Loss of loved one to covid
31	F	Professional	Survivor of covid infection
33	F	Professional	Boost self-confidence
34	F	Professional	Loss of loved one to covid
35	F	Professional	Loss of loved one to covid
35	F	Professional	Body adornment
35	F	Professional	Survivor of covid infection
23	M	Professional	Survivor of covid infection

A 23-year-old male presented with complaints of hypopigmentation and hypoesthesia over his left arm overlying a tattoo for 5 months. The patient gives a history of getting a tattoo approximately 1 year back from a local amateur tattoo artist post first lockdown. Examination showed a single hypopigmented, hypoesthetic patch of size approximately ten square centimeters present on the left arm encircling the tattoo [Figure 1]. Nerve examination showed bilateral and tender ulnar nerve thickening. Slit skin smear was 1+, and biopsy showed multiple well-defined granulomas composed of epithelioid cells, Langhans giant cells with histiocytes, and lymphocytes around dermal appendages, diagnostic of borderline tuberculoid Hansen’s disease.

Figure 1.

A Single hypopigmented patch of size 10x10cm present on the left arm strikingly encircled a tattoo

We also encountered five patients having similar lesions of well-defined hyperkeratotic plaque of variable duration present over a pre-existing tattoo. Histopathology revealed hyperkeratosis, parakeratosis, acanthosis, and mild papillomatosis of the epidermis. The superficial papillary and reticular dermis showed multiple granulomas composed of epithelioid cells, histiocytes, lymphocytes, and Langhans giant cells with central foci of caseous necrosis, which was diagnostic of tuberculosis verrucosa cutis.

Eight patients presented to our out-patient department (OPD) with severely pruritic erythematous annular plaques limited to the tattoo site of variable duration. The rest of the body was conspicuously spared. KOH displayed thin hyaline septate branching hyphae. Trichophyton rubrum was identified as the causative organism on culture. The diagnosis was tinea corporis.

We also came across nine patients with linear indurated papules and plaques of variable duration over the red ink of the tattoo. Biopsy was done in all the cases which showed lichenoid infiltrates with eosinophils suggestive of lichenoid reaction in six patients, while the remaining exhibited compact ortho-hyperkeratosis overlying a dense dermal infiltrate of lymphocytes of a small and moderate size with exocytosis diagnostic of pseudolymphoma. Moreover, four more patients presented to the OPD with indurated plaques which were limited to the tattoo site. After careful examination, they were clinically diagnosed as hypertrophic scar and confirmed histopathologically.

Another 30-year-old male presented with complaints of burning sensation over the tattoo site. On examination, a well-defined erythematous plaque with oozing and crusting was seen overlying the tattoo which was done 3 days back. The acute nature of the disease and the site of involvement being limited to the tattooed area led to a clinical diagnosis of irritant contact dermatitis.

We came across a patient with depigmented patches encircling a tattoo present on his left hand for 5 months [Figure 2]. There was a history of getting the tattoo 7 months back. We made a provisional diagnosis of contact leukoderma, but the patient returned after a month with complaints of fresh depigmented patches over other acral parts. Dermoscopy was done in the second visit, which showed an absent pigmentary network. Hence, a diagnosis of tattoo-induced vitiligo was made. The authors hypothesize that the introduction of tattoo pigment itself may have triggered the aberration in normal immune response, leading to vitiligo at the tattoo site and subsequently at other sites.

Figure 2.

Depigmented patches encircling a tattoo present on the left hand

Last, a 30-year-old female presented with multiple linear raised papules and plaques confined to his tattoo site for 6 months [Figure 3]. A punch biopsy was done, which revealed non-necrotizing granulomatous inflammatory infiltrate involving superficial and deep dermis along with black pigment consistent with tattoo ink within the granuloma. Hence, a diagnosis of sarcoidosis secondary to tattoo was established.

Figure 3.

Multiple linear raised papules and plaques confined to the tattoo site

Moreover, on inquiring about the reasons and place to get a tattoo during lockdown, all the patients gave various responses such as to gain self-confidence and feel motivated during a tragic time. Surprisingly, many patients got tattooed after losing their loved ones or after fighting off COVID infection themselves. Only four patients got their tattoo done by an amateur artist, while others chose a professional one [Table 3].

Discussion

Tattooing has become immensely popular among the young population leading to parallel rise in complications. There have been numerous reports of complications on a tattoo site in the literature. Tattoo reactions may be divided into three main groups: inflammatory, infectious, and neoplastic. Inflammatory presentations include focal edema, pruritus, papules, or nodules at the tattoo site. Histologically, they can be classified as lichenoid, eczematoid, foreign body granulomatous, and sarcoidal.[1] The infectious reaction can further be sub-divided into a bacterial, viral, or mycotic etiology. The infective complications could possibly be explained by the direct cutaneous inoculation over the tattoo site through contaminated instruments or due to a decrease in local, humoral, and cellular immunity due to black pigment in the tattoo ink.

Panda et al.[2] reported a series of four patients having tinea lesions over the tattoo site only and they were treated successfully with antifungal therapy. They hypothesized this phenomenon to the loss of local immunity which must be caused by the black ink as the other differently colored areas were spared.

The neoplastic complications within tattoo pigments includes keratoacanthoma, squamous cell and basal cell carcinoma, leiomyosarcoma, and melanoma.[3]

According to the literature, the most common tattoo site complication is an allergic contact dermatitis due to the pigments present in the tattoo. The main pigment of concern is the red one due to the presence of mercury and its sulfides.[4] The mechanism suggested in reactions to tattoo pigments include a localized, T-cell mediated, delayed hypersensitivity response (lichenoid and sarcoidal reaction). In addition, allergic reactions have been observed in the form of type I and III reactions, according to Coombs and Gell classification.[5] Currently, data are lacking regarding the safety of tattoo pigment ingredients. Also, none of the tattoo ink or additives are FDA-approved.

A review done by Cohen summarized the cutaneous viral tattoo site infections in the literature. These include HPV lesions (45 patients) and molluscum contagiosum (14 patients) as the most frequently reported tattoo site viral lesions. HPV lesions included verruca vulgaris (29 patients), verruca plana (14 patients), and human immunodeficiency virus (HIV)-associated acquired epidermodysplasia verruciformis (two men). Herpes compunctorum (three patients), vaccinia (two patients), and rubella (one patient) were less commonly reported.[6]

Based on the existing literature, we found various reasons for patients getting a tattoo which included body adornment, personal decoration, marker of identity, and expressions of individualism and even for overcoming difficult emotions as a means of affect management.[7] This holds true in our series, and many patients reportedly got a tattoo after losing a loved one or after recovering from COVID-19 infection during the pandemic.

Conclusion

In spite of a huge decrease in the patient foot fall during the pandemic time, we came across a good number of tattoo-associated adverse reactions, that is, 14 infective complications and rest of non-infective etiology. Therefore, it is important for dermatologists to be aware of these reactions as their occurrence is on the rise with increasing popularity of tattooing as a body art. Early diagnosis and treatment of such complications is a must. Moreover, general population should be made aware regarding the risks and side effects associated with getting a tattoo in order to make a wise decision. Consumers and medical professionals should be encouraged to report adverse reactions from permanent makeup to the drug controlling authority for regulation of cosmetic tattoo ink.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.