Papulo-Nodular Reactions in Black Tattoos as Markers of Sarcoidosis: Study of 92 Tattoo Reactions from a Hospital Material

Abstract

Background/Aims: Sarcoidosis is, from historical data, suggested to be more prevalent among patients with tattoo reactions. We aimed to evaluate this association in a systematic study. Methods: This is a consecutive study of patients with tattoo complications, diagnosed in the “Tattoo Clinic” at Bispebjerg University Hospital in Copenhagen, Denmark, from 2008 to 2015, based on clinical assessment and histology. From the overall group of 494 tattoo complications in 406 patients, 92 reactions in 72 patients showed a papulo-nodular pattern studied for local and systemic sarcoidosis, since sarcoidosis is expected to be nodular. Results: Of the 92 reactions with a papulo-nodular pattern, 27 (29%) reactions in 19 patients were diagnosed as cutaneous or systemic sarcoidosis, supported by histology; 65 (71%) were diagnosed as non-sarcoidosis due to histology and no clinical sarcoid manifestations. “Rush phenomenon” with concomitant reaction in many other black tattoos, triggered by a recent tattoo with a papulo-nodular reaction, was observed in 70% in the sarcoidosis group and 28% in the non-sarcoidosis group, indicating a predisposing factor which may be autoimmune and linked with sarcoidosis. Agglomerates of black pigment forming foreign bodies may in the predisposed individual trigger widespread reaction in the skin and internal organs. Conclusion: Black tattoos with papulo-nodular reactions should be seen as markers of sarcoidosis. Papulo-nodular reactions may, as triggers, induce widespread reactions in other black tattoos - a “rush phenomenon” - depending on individual predisposition. Sarcoidosis is estimated to be 500-fold increased in papulo-nodular reactions compared to the prevalence in the general population, and the association with black tattoos is strong.

Tattoo‐associated uveitis with or without systemic sarcoidosis: a comparative review of the literature

“…In case of a granulomatous reaction within a tattoo with uveitis, sarcoidosis should always be kept in mind as possible diagnosis and ruled out. As we stressed previously as well as other authors, the histopathology of sarcoidosis is challenging. It is not always possible for the dermatopathologist to draw a definite conclusion between sarcoidosis and foreign body granuloma.…”

“…Cases of sarcoidosis on tattoos have been reported since the beginning of the 40s . They usually present as infiltrated papules or nodules scattered on black tattoos, mostly in male patients . In our retrospective review of 67 cases of sarcoidosis cases in permanent tattoos and permanent make‐up from 1939 to 2011, six patients (9%) presented with ocular sarcoidosis and uveitis .…”

Micropapular Cutaneous Sarcoidosis Reviewed

“…A recent paper published by Sepehri et al [18] in 2016 demonstrates a strong association between black tattoos with papulonodular reactions and the development of systemic sarcoidosis. They hypothesize that in patients with papulonodular reactions the progression to systemic sarcoidosis is estimated to be increased 500-fold suggesting an autoimmune etiology of systemic sarcoid [18]. This proposed link of cutaneous sarcoidosis to an autoimmune theory could suggest that the skin in MPCS individuals is possibly somewhat compromised allowing quick development of eruptive micropapular sarcoidal granulomas.…”

“…However, in this form, the papules develop in already damaged (tattooed) tissue [16,17]. A recent paper published by Sepehri et al [18] in 2016 demonstrates a strong association between black tattoos with papulonodular reactions and the development of systemic sarcoidosis. They hypothesize that in patients with papulonodular reactions the progression to systemic sarcoidosis is estimated to be increased 500-fold suggesting an autoimmune etiology of systemic sarcoid [18].…”

Physicochemical characterization of inorganic deposits associated with granulomas in cutaneous sarcoidosis

“…It is well known that sarcoidosis preferentially affects sites with a prior injury as tattoos or scars. Polarizable material has been reported up to 22% of the cases suggesting that foreign material could be a nidus for granuloma formation and a potential trigger for the disease …”