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Delayed tattoo rash


A 26 year-old female presents with a papulo vesicular rash at the site of red dye six years after the tattoo. Is this type 4 allergy or another condition and how can I help this patient? How common is this problem?


The description is consistent with a cell mediated immune response to the tattoo although I would have expected more pain and itching than described. There are several questions in the archives of ATE related to reactions to tattoos. I was not able to find any additional information in the more recent literature relevant to your question. A portion of a question from 10/27/15 is:

“The colors of tattoos are made from various materials. Usually reds are from mercury compounds, blue from cobalt, green from chromium and yellow from cadmium. Most of the description of allergy to the dyes is to red colors (see Ask the Expert question below). Temporary tattoos made with henna have resulted in sensitivity to para-substituted amino-compounds leading to hair coloring sensitivity, but this would not be relevant to your patient. Tattoo technicians will often mix pigments to achieve a specific color and the mixtures will vary. Blue pigments include copper carbonate, sodium aluminum silicate, calcium copper silicate, other cobalt aluminum oxides and chromium oxides (Kaur 2009; Journal of Cosmetic Dermatology). Cobalt compounds are associated with a nonimmunologic contact urticaria which results in a transient urticaria after creation of the tattoo (Smith). Generalized urticaria, presumably immunologic, has also been described and was attributed to blue pigment, with resolution after removal of the tattoo (Bagnato). The pathophysiologic mechanisms for tattoo reactions include nonimmunologic histamine release, T cell mediated delayed reactions, granulomatous reactions, lichenoid reactions (resemble a graft versus host reaction), mast cell degranulation and pseudolymphomatous response.

In summary, I suspect the reaction you described is an immunologic response to the red dye in the tattoo as this is most common. The red dye is complex (see below) and may vary depending on the tattoo artist. Why a prolonged time may occur between the application of the tattoo and the symptoms and signs is not easily explained, but I suspect some event traumatized the skin, physical or UV light, and initiated the response. I cannot exclude other contributors from the dyes used in the tattoo. Treatments could be tried including moderate to high topical corticosteroids, calcineurin inhibitors or crisaborole. I would expect the topical corticosteroid to be most effective but cannot be used long term due to development of skin atrophy. I suspect that the tattoo will need to be removed to provide ultimate relief.

Schultz, Erwin, and Vera Mahler. "Prolonged lichenoid reaction and cross-sensitivity to para-substituted amino-compounds due to temporary henna tattoo." International Journal of Dermatology 41.5 (2002): 301-303.

Bagnato GF, De Pasquale R, Glacobbe O, Chirico G et al.Urticaria in a tattooed person. Allergol et Immunopathol 1992;27:32-3

Smith JD, Odom RB, Maibach HI. Contact allergy from cobalt chloride. Archives Dermatol 1975;111:1610-1

I hope this information is of help to you and your practice.
All my best.

Dennis K. Ledford, MD, FAAAAI

3/7/2014: Allergic reaction to red tattoo ink
Question: What information is available concerning diagnosis and treatment of Tattoo dye allergy? My patient with urticaria had severe swelling of the red colored portion of her tattoos.

Answer: There is a significant body of literature on allergic reactions to tattoos, and specifically to red dye tattoos. Such allergic reactions can be due to contact dermatitis and photoallergic dermatitis. The ink or pigment allergy causes an acute inflammatory reaction and sometimes can produce granulomatous, lichenoid, and pseudolymphomatous types of responses.

Specifically, red tattoo dye may contain the following:
1. Ferric hydrate (sienna)
2. Mercury sulfide (cinnabar)
3. Sandalwood
4. Brazilwood

As noted, reactions to red tattoo pigments account for the majority of the reactions. However, the evaluation of a patient with a possible reaction to tattoo dye is complex because many times the dyes are mixed by the person applying the tattoo, and tattoo inks change their composition over time.

To my knowledge, treatment is limited to removal of the tattoo usually using laser surgery. I have copied for you below a review of allergic reactions to tattoos which discusses this treatment.

Thank you again for your inquiry and we hope this response is helpful to you.

J Am Acad Dermatol. 2011 Jun;64(6):1111-4. doi: 10.1016/j.jaad.2010.11.005.
Treatment of tattoo allergy with ablative fractional resurfacing: a novel paradigm for tattoo removal.
Ibrahimi OA1, Syed Z, Sakamoto FH, Avram MM, Anderson RR.

Kaur RB et al: Cutaneous allergic reactions to tattoo ink
Journal of Cosmetic Dermatology
Volume 8, Issue 4, pages 295–300, December 2009
Tattoo artists use many compounds to create tattoo pigment and several allergic reactions can occur as a result of these additives. The compositions of many inks have been identified; however, as new mixtures are created it becomes difficult to identify the specific ingredients in a particular ink. Allergic reactions to a particular pigment can manifest in several ways including allergic contact dermatitis and photoallergic dermatitis. Subsequently, tattoo ink or pigment allergy reactions can be classified as acute inflammatory reactions, allergic hypersensitivities, and granulomatous, lichenoid, and pseudolymphomatous types of reactions. This paper will review the clinical manifestations and the most common compounds associated with cutaneous reactions to tattoo ink.

Phil Lieberman, M.D.