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A 40-year-old man presented with intractable pruritus within portions of a tattoo imprinted with red ink on the left leg (Panel A). The intense localized itching had begun approximately 4 months after placement of the tattoo. Topical and intralesional corticosteroids and laser therapy all had no effect. Histologic sections of the resected skin revealed an intense, chronic inflammatory reaction to tattoo pigment, characterized by moderate, irregular epidermal hyperplasia, marked dermal fibrosis, and a dense, patchy infiltrate of lymphocytes and histiocytes surrounding the areas of granular, refractile red pigment (Panel B, arrows). Other areas, nearly devoid of inflammation and fibrosis, showed only granular black pigment between collagen bundles of the superficial dermis (Panel B, arrowhead). Allergic reactions to tattoos are a recognized complication of tattooing, along with infection, inoculation of warts, and scarring. Hypersensitivity to red pigments is most common, especially those containing mercuric sulfide (cinnabar). The failure of alternative treatments and the patient's continued symptoms prompted excision and split-thickness graft repair.
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