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Abstract

  1. Top of page
  2. Abstract
  3. Case Report
  4. Discussion
  5. Acknowledgments
  6. References

A 27-year-old woman presented with linear, flesh-colored papules along her vermillion borders, 4 years after a cosmetic lip tattoo was applied. A biopsy of the lesion was performed and histology showed it to be a granulomatous reaction surrounding the tattoo pigment. Following the biopsy, the lesions began to resolve spontaneously within 4 weeks and were not noticeable at a follow-up review. Granulomatous reactions are rare after cosmetic facial tattoos and may respond to topical corticosteroids or laser ablation. We present a unique report of a delayed granulomatous reaction to a cosmetic tattoo completely resolving without any specific treatment.


Case Report

  1. Top of page
  2. Abstract
  3. Case Report
  4. Discussion
  5. Acknowledgments
  6. References

A 27-year-old female presented with a 4-month history of a papular eruption along the vermillion border of her upper and lower lip. Apart from cosmesis the lesions were asymptomatic. Her only treatment prior to our review was topical acyclovir without benefit. Four years prior to the presentation, the patient had a cosmetic lip-liner called “rose red” tattooed along both vermillion borders on two occasions with no immediate complications. The constituents of this micropigment were iron oxide, titanium dioxide, glycerin, and ethanol.

On examination there were discrete, elongated, yellowish papules on the upper vermillion border and several more coalescing in a linear arrangement along the lower vermillion border (Fig. 1a). Residual cosmetic tattoo pigment was evident along both borders.

image

Figure 1. (a) The lips of the patient showing yellowish papules in a linear arrangement along both vermillion borders at the time of presentation. Cosmetic tattoo pigment is evident along both vermillion borders. (b) Same area seen at a subsequent review following a 3-mm punch biopsy of one of the lesions on the lower lip. There was no clinical evidence of residual granulomas

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Clinical impression was either a reaction to the tattoo pigment or xanthomas considering the yellowish color of the papules. The histology from a 3-mm punch biopsy showed a dense histiocytic and granulomatous inflammatory reaction in the dermis with abundant finely granular pigmentation (Fig. 2). This was consistent with a granulomatous reaction to tattoo pigment. The patient was referred on for an opinion regarding laser therapy. However, within 4 weeks of the punch biopsy, all of the lesions began to resolve spontaneously and were not clinically evident at a follow-up review (Fig. 1b).

image

Figure 2. Dense histiocytic and granulomatous reaction in the dermis with abundant, fine granular pigmentation. (hematoxylin and eosin, original magnification, ×40)

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Discussion

  1. Top of page
  2. Abstract
  3. Case Report
  4. Discussion
  5. Acknowledgments
  6. References

Cosmetic face tattooing was first introduced in the 1980s.1 Over the past 10 years cosmetic facial tattoos in the form of semipermanent makeup application to eyebrows, eyelids, and lips have become increasingly popular. However, reports of reactions to cosmetic tattoos are still uncommon in the literature. Foreign body granulomatous reactions are more common after decorative body tattoos and have been reported in several tattoo pigments including areas of black,2 red,3 and purple pigments.4

The limited reports of granulomatous reactions in cosmetic tattoos include two patients developing granulomas, 2 months after cosmetic eyebrow tattooing.5 The pigment compounds shown on X-ray microanalysis were calcium, silicon, titanium, zinc, copper, sulfur, aluminum, and magnesium. In a further case involving a red cosmetic lip tattoo, an edematous reaction occurred more acutely within days of the second application of pigment followed by the development of coalescing granulomatous papules after a year.6 In this case the constituents in the red pigment were iron oxide, naphthanil red, alcohol, and glycerin. In our case we can only speculate that the causative agent for the delayed reaction was either iron oxide or the titanium dioxide.

The most interesting aspect of this case is the rapid resolution following biopsy. There have been previous reports of the granulomas in granuloma annulare resolving after punch biopsy although the association is controversial.7 No previous reports could be found of granulomatous reactions in cosmetic tattoos resolving spontaneously or following minimal biopsy trauma. Possible reasons for resolution of the granulomas could be related to the inflammatory process and wound-healing mechanism following biopsy. This process changes the cellular and cytokine environment in the granuloma and along with the subsequent remodelling of the extracellular matrix may lead to ultimate resolution of the lesions.7 This does not fully explain why all the lesions resolved in this case and not just the lesion where biopsy specimen was taken.

Granulomatous tattoo reactions may respond to topical steroids or persist for months or years despite treatment with topical or intralesional steroids.2,6 Ablation with either the carbon dioxide laser or Q-switched laser is another method of removing cosmetic tattoos1,8 or tattoo reactions.9 Pink or red permanent lip-liner can permanently blacken after Q-switched laser ablation due to iron oxide or titanium dioxide shifting from their oxidized to reduced states.10 Therefore, with pink to red pigments and anatomical locations such as the lips, carbon dioxide laser ablation may be the laser treatment of choice.6

Our case illustrates a unique association of a granulomatous reaction in a cosmetic tattoo that resolved spontaneously or with minimal biopsy trauma. These granulomatous reactions are likely to become more common with the increasing trend of cosmetic tattooing or semipermanent makeup application.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Case Report
  4. Discussion
  5. Acknowledgments
  6. References

The authors would like to thank Dr. Marie Staunton (histopathologist) for her kind assistance with the histological material in this report.

References

  1. Top of page
  2. Abstract
  3. Case Report
  4. Discussion
  5. Acknowledgments
  6. References