Inflammatory Tattoo Reaction (2023)

Are You Confident of the Diagnosis?

  • What you should be alert for in the history

Most tattoos are the result of intentional placement of exogenous insoluble pigments into the dermis via repeated needle punctures for the purposes of decoration or on the basis of one’s culture.

Other less commonly encountered tattoo forms include cosmetic enhancement such as permanent lip liner or eyeliner, reconstructive surgery such as breast reconstruction, accidental or traumatic tattoos and iatrogenic. Traumatic tattoos can be abrasive in nature from dirt or gravel (Figure 1, Figure 2), or explosive such as shrapnel or gunpowder. Iatrogenic tattoos can be unintentional like those following the use of ferrous subsulfate (Monsel’s solution) for hemostasis, or intentionally placed for the purpose of medical treatments, such as radiation.

Figure 1.
Inflammatory Tattoo Reaction (1)
Figure 2.
Inflammatory Tattoo Reaction (2)

Tattoo reactions can occur at any time following initial placement and can occasionally even arise following placement of additional tattoos several years after the first.

Acutely, scaling, crusting and tenderness are seen almost universally secondary to the mechanical injury sustained by the skin during the application of the tattoo and are expected to resolve within weeks as the skin heals.

Patients may present with various signs and symptoms such as intense pruritus, erythema, induration, edema and tenderness.

The more recent trend of henna tattoos can result in a significant allergic contact dermatitis occurring anywhere from 24 hours to 2 weeks after the “holiday tattoo.” The responsible allergen is typically paraphenylenediamine.

Delayed type hypersensitivity reactions can occur from weeks to years later. The presenting complaint is most commonly either erythematous nodules/plaques, a lichenoid reaction or eczematous eruption at the site of the tattoo. Patients may also present with asymptomatic nodules and concerns regarding cosmesis and scarring.

Less commonly reported symptoms include intense pruritus and erythema associated with or following UV/sun exposure. In most of these cases, tattoos contain either red and/or yellow pigments, which account for the photosensitive or photoallergic reaction.

Lymph nodes can also become inflamed due to the migration of tattoo pigments to the node via lymphatic drainage.

  • Characteristic findings on physical examination

Tattoo reactions can present in a wide range of clinical patterns. Often erythema, pruritus, indurated papules or nodules are characteristically seen within certain areas or borders of the tattoo graphic. Scaling, crusting and ulceration may be present as well (Figure 3, Figure 4, Figure 5, Figure 6). Other reaction patterns include granulomatous, lichenoid, photoallergic, eczematous, urticarial or keratoacanthoma type verrucoid papules. Rarely transient focal hyperkeratosis has occurred following temporary henna tattoos. Not uncommonly, patients may also have a concomitant generalized eruption related to id type auto-sensitization.

Figure 3.
Inflammatory Tattoo Reaction (3)
Figure 4.
Inflammatory Tattoo Reaction (4)
Figure 5.
Inflammatory Tattoo Reaction (5)
Figure 6.
Inflammatory Tattoo Reaction (6)

Certain clinical patterns provide clues to underlying basis for the reaction. In reported cases of atypical mycobacterial inoculation, asymptomatic or pruritic papules, notably with pustules, developed 10 to 21 days following tattoo application. In these cases, lesions were confined to specific areas of the tattoo, generally identical pigment sections or areas utilizing a specific pigment as part of a mixed compound. In both reports, infections were associated with pigment made from a grey wash compounded from diluting black pigment with non-sterile water, the presumed source.

When evaluating tattoo reactions, it is also important to consider coincidental lesions, including sarcoidosis, infectious processes such as verruca, fungal and atypical mycobacteria as well as malignancies such as B-cell lymphoma, melanoma, basal cell carcinoma, non-Hodgkin’s lymphoma or squamous cell carcinoma.

  • Expected results of diagnostic studies

Given the wide range of clinical reaction patterns, it is not unexpected that there is also a wide range of histologic patterns with tattoo reactions.

A granulomatous pattern is perhaps the most common reaction noted histologically. It can be classified as either foreign body or sarcoidal, however, the distinction can be difficult. The predominant feature in foreign body reaction is the presence of abundant giant cells compared with sarcoidal lesions, which are marked by clusters of epithelioid histiocytes. Most tattoo pigments appear black on hematoxylin and eosin stain despite the true pigment color.

(Video) Tattoos. Part 2 - Inflammatory reactions

Another pattern noted has been massive pseudoepitheliomatous hyperplasia. One report noted pruritic nodules, which developed 2 months after tattoo placement. Verrucoid papules were appreciated clinically, and an initial biopsy demonstrated epidermal hyperplasia suggestive of a regressing keratoacanthoma. Repeated sampling showed marked epidermal hyperplasia, focal cystic keratin dilations, mild reactive keratinocyte atypia as well as dense chronic inflammation, fibrosis and red pigmented granules in the surrounding dermis.

Similarly, eruptive keratoacanthomas have also been noted histologically. In one case, four nodules arose in a single tattoo 3 weeks following application. Pathology from each distinct nodule showed invasive areas of atypical glassy keratinocytes extending into the dermis along with both free and histiocyte-laden pigment.

A rarely reported pattern is a morphea-like tattoo reaction. In one case, the clinical presentation demonstrated typical symptoms of pruritus, inflammation and induration, but notably, the reaction affected multiple different pigments. Biopsy demonstrated lymphoid infiltrate, plasma cells, free and bound tattoo pigment as well as thickened, hyalinized collagen, loss of peri-eccrine fat in addition to proliferation of interstitial fibroblasts. Additional stains showed reduced elastic tissue, suggesting a nonspecific sclerosing response to the foreign material.

In some cases, multiple reaction patterns may be present as a result of distinct immunologic responses to the different pigment compounds. In one instance, a patient developed simultaneous reactions to multiple pigments following re-tattooing over unwanted tattoos. In this case, biopsy from the reactive red pigment area demonstrated a mild lymphocytic infiltrate along with lichenoid changes at the dermal-epidermal junction and was classified as a lichenoid reaction.

Another biopsy taken from a nodular area of light blue pigment in a separate reactive tattoo demonstrated an intense inflammatory infiltrate of large lymphocytes and pigment-laden macrophages filling the upper dermis consistent with a pseudolymphomatous tattoo reaction. Notably the sample lacked germinal center or lymphoid follicule formation, and additional studies using immunohistochemical markers demonstrated a mixed infiltrate with T-cell predominance. T-cell gene rearrangement showed polyclonal expansion, suggesting that the process was reactive.

  • Diagnosis confirmation

Sarcoidosis, a chronic granulomatous disease of uncertain etiology, can confound the evaluation of tattoo reactions. Granulomatous inflammation is one of the more common reaction patterns noted with tattoo reactions, yet as many as 25% of patients with sarcoidosis may present with cutaneous manifestations, namely cutaneous granulomas that can preferentially appear within tattoos. Given that the clinical presentation can be nearly identical, a screening workup should be considered to rule out systematic sarcoidosis in these patients.

Cutaneous or extra-nodal lymphoma can also pose a diagnostic challenge. Clinically these lesions will appear as erythematous, plum colored or violaceous nodules. Histologically, pseudolymphomatous reaction patterns can be difficult to distinguish from lymphoma. It is important to consider additional immunohistochemical tests and clonal gene rearrangement studies to avoid misdiagnosis in these cases.

Infectious agents including certain bacterial, fungal, tuberculosis or atypical mycobacterial organisms may also present in a similar manner to tattoo reactions. Inoculation of infectious organisms can be due to the mechanics of tattooing, such as the use of inappropriately sterilized equipment, use of non-sterile water sources for dilution of inks, or by contamination of freshly tattooed skin from poor wound care.

The clinical appearance of pustules or purulent drainage may be indicative of an underlying infectious process. Histologically, pseudoepitheliomatous hyperplasia or granulomas may be present, which can also be seen in tattoo reactions. Special stains such as GMS along with appropriate tissue cultures are indicated to ensure proper diagnosis.

Who is at Risk for Developing this Disease?

Tattoo reactions are possible following any type of tattoo: graphic/intentional, temporary henna, iatrogenic, cosmetic and even traumatic tattoos.

Frequently patients who develop tattoo reactions are later found to have an underlying allergy or sensitization to metallic substrates in the pigment compound. This can on occasion be determined with use of patch testing, which is helpful when it demonstrates a positive result. It is important to note that a negative patch test does not necessarily rule out the possibility of allergy due to the immunologic differences between intradermal pigment deposition and the transdermal application of the compounds with patch tests.

Patients with a known history of sarcoidosis may be at higher risk of developing a tattoo reaction, however, it is not uncommon for the onset of the systemic form to occur many years following tattoo placement.

What is the Cause of the Disease?

  • Etiology

Many cases of lichenoid reactions have been associated with mercury-based red pigments. However, mercury sulphide (cinnabar) content is now restricted to much lower concentrations, which may help reduce the number of reactions to some degree. Importantly, substitute compounds such as cadmium red or yellow can also lead to allergic as well as photoallergic reactions. Other organic-based dyes have also been used in place of mercuric pigments, and typically patch testing to these substances will be negative, further complicating evaluation.

In general, metallic substrates used in the pigment compounds are felt to be at the root of most reactions, and occasionally patch testing with corresponding metal may help demonstrate causality.

Commonly associated compounds and pigments include mercury with red, cobalt with blue, cadmium with both yellow and red, chromium with green, and manganese with purple. Carbon (india ink) and iron oxide are common in black pigment.

The principle agent responsible for type IV hypersensitivity reactions from black henna tattoos is not the henna itself, but paraphenylendiamine (PPD), which is added to create darker coloring and shorter drying time.

(Video) My Tattoo INFECTION Experience - HORRIFYING!

PPD is known to cross-react with a number of substances including para-amino benzoic acid, sulfonamides, sulfonylureas, dapsone, azo dyes and benzocaine. It is important for patents with known allergy to any of these substances to avoid temporary tattoos, especially those marketed as “black henna,” which generally contain PPD.

  • Pathophysiology

Delayed type hypersensitivity reactions mediated by a T-cell response likely account for the majority of tattoo reactions, generally leading to either granulomatous or lichenoid processes.

Other suggested pathophysiologic mechanisms include B-cell mediated responses yielding pseudolymphomatous changes as well as photoallergic/ photosensitive reactions, which lead to chronic eczematous dermatitis, both clinically and pathologically. Koebner phenomenon has also been demonstrated.

Given the wide range of distinct clinical and histopathologic findings, it seems likely that a complex interplay of pigment substrates and immunologic processes is responsible for the reactions.

Systemic Implications and Complications

Sarcoidal granulomas occurring within tattoo reactions present a diagnostic challenge as this reaction pattern may be a cutaneous manifestation of systemic sarcoidosis, sarcoid limited only to the skin (so-called cutaneous sarcoidosis) or purely a local reactive granulomatous response.

It is therefore considered prudent to rule out systemic sarcoidosis. This chronic granulomatous disease is defined by presence of certain clinical symptoms, radiographic findings and histologic changes (specifically noncaseating epithelioid-cell granulomas) affecting two or more organ systems in the absence of any other possible cause for a systemic granulomatous reaction.

Symptoms associated with systemic sarcoidosis include fever, malaise, weight loss, pulmonary issues such as dyspnea, dry cough, chest discomfort, lymphadenopathy, and ocular complications such as anterior uveitis.

Less commonly noted signs and symptoms include neuropathy, cranial nerve palsy (seventh notably) or mental status changes related to central nervous system involvement. Other systems affected less commonly include cardiac, hepatic, osseus or bony changes, muscular weakness, hematologic, rheumatologic, endocrine and renal.

A well rounded screening evaluation for systemic sarcoidosis should include a chest X-ray along with basic labs such as CBC with differential, liver function tests and a basic metabolic panel. Additional screening labs might also include serum calcium levels (assessing for hypercalcemia), erythrocyte sedimentation rate (ESR) and antinuclear antibody (ANA) levels. PPD placement is also recommended.

Serum angiotensin-converting enzyme (ACE) is not a sensitive screening tool as this can be elevated in the absence of sarcoidosis. However, once the diagnosis of sarcoidosis has been confirmed serum ACE levels can be monitored as a reflection of disease activity.

Another diagnostic dilemma with regard to tattoo reactions is the distinction between pseudolymphoma versus lymphoma. Pseudolymphomatous reactions can appear very similar to lymphoma. Clinically, pseudolymphomatous reactions are characterized by plum to violet hued firm nodules and are often solitary or localized. However, in the case of tattoo reactions, multiple lesions can occur. Histologically, pseudolymphomas characteristically demonstrate a mixed inflammatory infiltrate higher in the dermis than seen with lymphomas, accompanied by germinal center formation and macrophages.

Distinguishing pseudolymphoma from lymphoma often necessitates special stains and clonal rearrangement studies to characterize the infiltrate. A polyclonal pattern tends to favor pseudolymphoma whereas light chain restriction for either kappa or lambda are more suggestive of lymphoma.

Treatment Options

Medical options

Topical therapies

Potent corticosteriods

Intralesional corticosteroids

Systemic therapies

(Video) How To Tell If Your Tattoo Is Infected

Steroid taper


Destructive options

Surgical removal

Excision followed by split thickness skin graft

Mechanical removal


Laser ablation

Optimal Therapeutic Approach for this Disease

In most cases, the initial therapeutic approach should be conservative management. Superpotent topical steroids, such as clobetasol propionate 0.05%, can be applied twice daily. Improvement should occur within 2 to 4 weeks of treatment. It is difficult to predict which patients may respond, but in general overall effectiveness is considered low.

The next step in management is often dictated by the patient’s desire for preservation of his or her tattoo. Should the patient desire to preserve the tattoo, intralesional kenalog (5 to 10mg/mL dose) may be injected into the affected areas. Patients should be aware that injections will likely need to be repeated about every 8 to 12 weeks to prevent recurrence of the underlying reaction. Additional risks include steroid atrophy due to use of intralesional steroid. This risk can be reduced by using the lowest potency concentration to achieve clearance.

For allergic contact dermatitis reactions to temporary henna tattoos, a short systemic steroid taper is highly effective. This can be combined with oral hydroxyzine and topical corticosteroids for optimal relief.

While some reports have documented effective removal of inflamed or reactive tattoos using lasers, the process does not have widespread acceptance due to the risk of a disseminated cutaneous reaction as well as the potential risk of anaphylaxis. Careful examination of the literature should be done prior to proceeding with laser ablation with special attention to the type of laser used in the report, the location of the tattoo and the presence of additional tattoos (in as much as laser treatment of a single tattoo may incite reaction in uninvolved tattoos).

The definitive treatment for severe persistent tattoo reactions is surgical excision, which based on size and location, may require skin grafting.

Patient Management

Patients will generally guide follow-up on the basis of clinical symptoms or from the desire to preserve the affected tattoo. With topical therapies, clinical response should be evident within 2 to 4 weeks, making 4 weeks a reasonable time for follow-up visit, unless the presentation was very severe or complicated, in which case a 2-week follow-up would be indicated. Maintenance therapy is dependent upon the treatment modality, with intralesional steroids requiring ongoing treatment for suppression of the reaction.

Failure of conservative therapies may necessitate the discussion of surgical excision.

Patients who present with allergic contact dermatitis to a temporary henna tattoo should be educated about the risk of sensitization to PPD and cautioned to avoid henna-based tattoos in the future and hair dyes that might also contain PPD.

Unusual Clinical Scenarios to Consider in Patient Management

Sarcoidal type granulomas can be associated with tattoo reactions. Additionally, patients with tattoos are at an increased risk of acquiring chronic hepatitis C. A unique clinical scenario has been noted in patients with chronic hepatitis C following initiation of interferon alpha, which has become a mainstay medication used to suppress viral proliferation.

While it has been well known that interferon alpha could induce immune-mediated diseases such as sarcoidosis, recent reports have detailed the appearance of sarcoidal granulomas in tattoos following the use of interferon alpha even 4 to 8 weeks after cessation of treatment. In these cases, it remains critical to complete a full systemic screening examination for signs or symptoms of systemic sarcoidosis.

(Video) Tattoos and chronic inflammatory diseases and immunosuppressive treatments

Another challenging clinical scenario regarding tattoo reactions involves patients who are found later to have malignant melanoma. In one report, a 25-year-old patient was diagnosed with a 1mm thick melanoma involving the chest. Given the depth, sentinal lymph node biopsy was undertaken. Radiotracer uptake was noted in the bilateral axillae, and subsequent surgical excision revealed deeply pigmented lymph nodes in each axillae grossly suggestive of metastatic disease.

Given the young age of the patient, intraoperative frozen sections were carried out prior to completion dissection. Careful microscopic evaluation demonstrated reactive follicular hyperplasia with extracellular black coarse granules throughout the sinuses. Findings were correlated with hematoxylin and eosin stains along with special stains including S-100, cytoplasmic homatropine methylbromide (HMB-45) and Fontana-Masson, which were all negative for metastatic disease.

This case serves as a reminder that even with strong clinical suspicion, histologic confirmation of metastatic disease should be fully confirmed prior to proceeding with what could be an unnecessary completion lymphadenectomy, especially given the well known morbidities associated with completion dissection.

What is the Evidence?

(Excellent FDA consumer update summary regarding the risks of tattoos.)

Kennedy, BS, Bedard, B, Younge, M, Tuttle, D, Ammerman, E, Ricci, J, Doniger, AS, Escuyer, VE, Mitchell, K, Noble-Wang, JA, O’Connell, HA, Lanier, WA, Katz, LM, Betts, RF, Mercurio, MG, Scott, GA, Lewis, MA, Goldgeier, MH. “Outbreak of Mycobacterium chelonae infection associated with tattoo ink”. N Engl J Med. vol. 367. 2012. pp. 1020-4. (Study showing the development of M. Chelonae infection after using contaminated premixed grey tattoo ink. The manufacturer has subsequently recalled this ink.)

Kluger, N, Muller, C, Gral, N. “Atypical mycobacteria infection following tattooing: Review of an outbreak in 8 patients in a French tattoo parlor”. Arch Dermatol. vol. 144. 2008. pp. 941-2. (A case series from France detailing 8 patients who all received tattoos from a single artist at a single tattoo parlor, each presenting within a 5-month period with asymptomatic erythematous papules and pustules strictly confined to the grey areas of the tattoos. Subsequent assessment revealed a positive acid-fast bacilli staining sample from the tattoo ink, which had been made using non-sterile tap water to dilute black ink to grey. The outbreak was presumed to be an atypical mycobacterial infection despite negative cultures given histopathology as well as clinical response to routine antibiotics effective against atypical mycobacterial infections, namely minocycline, clarithromycin or topical bacitracin/neomycin.)

Drage, L, Ecker, P, Orenstein, R, Phillips, K, Edson, R. “An outbreak of Mycobacterium chelonae infections in tattoos”. J Am Acad Dermatol. vol. 62. 2009. pp. 501-6. (A case series of six patients who developed M chelonae infections after receiving tattoos at a single tattoo parlor from a single tattoo artist. Clinical findings appeared 1 to 2 weeks following tattoo placement in all patients, and symptoms included pink, red or purple papules, papules with scales, pustules, granulomatous papules, and lichenoid papules and plaques. Cultures were positive in three patients. The diagnosis was made by histopathology in two cases and by clinical association in one remaining case. All isolates were clarithromycin sensitive.)

Balfour, E, Olhoffer, I, Leffell, D, Handerson, T. “Massive pseudoepitheliomatous hyperplasia: an unusual reaction to a tattoo”. Am J Dermatopathol. vol. 25. 2003. pp. 338-40. (A case report of pruritic, verrucous plaques arising 2 months following tattoo placement. Superficial shave biopsy initially revealed epidermal hyperplasia suggestive of a regressing keratoacanthoma. Repeat shave biopsy demonstrated marked epidermal hyperplasia with focal keratin-filled cystic dilations, reactive keratinocyte atypia, dense chronic inflammation, fibrosis and granules of dark red pigment suggesting pseudoepitheliomatous hyperplasia secondary to the tattoo.)

Chorny, J, Stephens, F, Cohen, J. “Eruptive keratoacanthomas in a new tattoo”. Arch Dermatol. vol. 143. 2007. pp. 1457-8. (A case report of multiple crusted nodules arising 3 weeks following tattoo placement. Histopathology showed invasive broad tongues of atypical glassy keratinocytes extending into the dermis. The sample was also notable for tattoo pigment free within the dermis as well as contained within scattered histiocytes. No recurrence of tumors were noted within 6 months following surgical excision.)

Mahalingam, M, Kim, E, Bhawan, J. “Morphea-like tattoo reaction”. Am J Dermatopathol. vol. 24. 2002. pp. 392-5. (A case report of tattoo reaction developing 1 year after tattoo placement characterized by pruritus, inflammation and induration. A punch biopsy sample demonstrated superficial and deep perivascular and periappendageal lymphoid cell infiltrate within scattered plasma cells, both intra- and extracellular depostition of tattoo pigment, thickening and hyalinization of collagen, interstitial fibroblast proliferation and loss of perieccrine adipocytes. Large amounts of hemosiderin deposition was noted in the mid-dermis, and Verhoeff von Gieson stain revealed fragmented, markedly reduced elastic fibers suggesting the diagnosis of morphea-like tattoo reaction. Full skin examination showed no additional clinical lesions suggestive of morphea.)

Chave, T, Mortimer, N, Johnston, G. “Simultaneous pseudoepitheliomatous and lichenoid tattoo reactions triggered by re-tattooing”. Clin Exp Dermatol. vol. 29. 2004. pp. 197-9. (A case report of asymptomatic nodules arising in several tattoos 6 months after re-tattooing over two unwanted longstanding prior tattoos. One re-tattooed area demonstrated an indurated plaque involving several multicolored areas of the newest tattoo, but was limited to the red pigmented areas of the original underlying tattoo. Biopsy from this area showed a lichenoid reaction to red tattoo pigment.A separate tattoo on the back was found to have multifocal nodular reaction to newly applied light blue pigment, and older longstanding tattoos on the forearms also developed multiple small focal areas of nodular reaction within the longstanding blue pigment. Biopsy of the re-tattooed lesion on the back demonstrated pseudolymphomatus tattoo reaction. Patch testing to undiluted pigments was negative. Clinical improvement was noted following several months of using clobetasol propionate 0.05% cream twice daily.)

Arroyo, M. “Black henna tattoo reaction in a person with sulfonamide and benzocaine drug allergies”. J Am Acad Dermatol. vol. 48. 2003. pp. 301-2. (A case report of significant allergic contact dermatitis arising 24 hours following the placement of two black henna temporary tattoos in a man with a history of sulfonamide and benzocaine allergy, highlighting the significance of parapheylenediamine allergy and the high cross reactivity risk with substances such as sulfonamides, sulfonylureas, dapsone, azo dyes and benzocaine.)

Morales-Callaghan, A, Aguilar-Bernier, M, Martinez-Garcia, G, Miranda-Romero, A. “Sarcoid granuloma on black tattoo”. J Am Acad Dermatol. vol. 55. 2006. pp. S71-3. (A case report of tattoo reaction arising 10 months following tattoo placement. Histopathologically, sarcoid granulomas were noted in the areas of black pigment. Patch testing showed type IV sensitization reaction to nickel and cobalt. Both metallographic reflection microscopy and flame atomic absorption spectrophotometry highlighted metals confined to black pigmented areas.)

Nawras, A, Alsolaiman, M, Mehboob, S, Bartholomew, C, Maliakkal, B. “Systemic sarcoidosis presenting as a granulomatous tattoo reaction secondary to interferon-alpha treatment for chronic hepatitis C and review of the literature”. Dig Dis Sci. vol. 47. 2002. pp. 1627-31. (A case report of tattoo reaction occuring 1 month following a 4-week course of recombinant interferon-α 2b for chronic hepatitis C. The interferon-α 2b had been discontinued due to progressive malaise and dyspnea. Biopsy of subcutaneous nodules involving a longstanding tattoo showed noncaseating granulomatous inflammation in proximity to pigment fragments. Given pulmonary symptoms, systemic workup was undertaken revealing bulky scattered lymphadenopathy, which was confirmed on biopsy as noncaseating granuloma and lymphocytic infiltration leading to diagnosis of both cutaneous and systemic sarcoidosis.)

Friedman, T, Westrich, M, Mozes, S, Dorenbaum, A, Herman, O. “Tattoo pigment in lymph nodes mimicking metastatic malignant melanoma”. Plast Reconstr Surg. vol. 111. 2003. pp. 2120-2. (A case report of a 25-year-old male undergoing sentinal lymph node biopsy of bilateral axillae following diagnosis of a 1mm malignant melanoma arising on the chest. The patient had multiple decorative tattoos over both arms. Sentinal lymph node dissection from each axillae was concerning for macroscopic deep, dark gray pigmentation, which was suspected to be metastatic melanoma.Intraoperative frozen section analysis along with multiple staining protocols were done prior to completion dissection, and was found to be negative for metastatic melanoma, revealing instead benign tattoo pigment deposition and sparing the patient unnecessary surgical morbidity.)

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Jump to Section
  • Are You Confident of the Diagnosis?
  • Who is at Risk for Developing this Disease?
  • What is the Cause of the Disease?
  • Systemic Implications and Complications
  • Treatment Options
  • Optimal Therapeutic Approach for this Disease
  • Patient Management
  • Unusual Clinical Scenarios to Consider in Patient Management
(Video) Tattoo Reaction/Rash - pseudo-lymphoma mimic of mycosis fungoides (Stony Brook case 2) dermpath


How long does it take for a tattoo allergic reaction to go away? ›

Acute inflammatory allergic reaction.

This occurs because of the irritation caused by the tattoo needle and the tattoo ink. It's not serious, and generally subsides within about two or three weeks.

What is an acute inflammatory reaction to tattoo? ›

An acute inflammatory reaction is in direct response to the piercing of the skin with needles impregnated with pigment dyes prepared from metal salts. There may be transient redness and swelling of the area that disappears within 2–3 weeks. It is an expected side effect of the tattooing process.

What does an allergic reaction to tattoo ink look like? ›

Swelling and redness around a tattoo. Itchy rash of tiny bumps. Blisters or hives.

Can I take Tylenol to reduce tattoo swelling? ›

“You can take things like over-the-counter painkillers, but the sharp pain you have at the surface of the skin will still likely be felt during the procedure.” You can take acetaminophen (like Tylenol) or ibuprofen (like Advil) can help with any soreness that occurs in the hours after you get your tattoo, but there's ...

Is ibuprofen good for tattoo inflammation? ›

Take anti-inflammatory medicines to reduce pain and swelling. These include ibuprofen (Advil, Motrin) and naproxen (Aleve).

Can you sue tattoo artist for allergic reaction? ›

In rare cases, clients can have an allergic reaction to the pigment you use in your tattoos, as well as substances you use to prepare the skin before beginning your work. If the allergic reaction is severe, the client may file a lawsuit against your tattoo shop to recover compensation.

Is a tattoo allergy serious? ›

Tattoo ink allergy is a fairly rare condition, but it can be a serious problem. If you're having an allergic reaction to your tattoo, you'll need to see a doctor immediately.

When should I be worried about a tattoo rash? ›

A mild to moderate tattoo rash should clear up in a week or two. If your rashes last longer than that, maybe it is time to see a doctor. Also, some scarring or swelling of the tattoo area while it is healing is quite normal. If it disappears in a week and does not return, you won't need to worry about it.

What does an inflamed tattoo look like? ›

An infected tattoo can be serious. The area around your tattoo may be painful, swollen, red, and hot. You may see red streaks or pus at the tattoo site. You may have a fever or swollen or tender lymph nodes.

Is it normal for a new tattoo to be red and swollen? ›

It's normal for your tattoo to be red and maybe even slightly puffy in the days after you get it done. If the redness persists, it may be an early sign that something is wrong. Oozing liquid. If fluid (especially green or yellowish in color) is oozing from your tattoo after a week, see your doctor.

Why is my tattoo still inflamed? ›

Extreme redness of the skin: Most tattoos are inflamed and red right after they've been done, but if the redness intensifies rather than resolving within a week of the procedure, you may have an infection.

What do I do if I'm having an allergic reaction to my tattoo? ›

If you're having an allergic reaction to your tattoo, you might get a rash that's red, bumpy, or itchy. These symptoms can crop up in the days after you first get your tattoo or can appear months or years later. You can most likely treat the area with a steroid ointment.

Can Benadryl help with itchy tattoo? ›

For intense itching, washing and reapplying your moisture product may help – if not, consider taking an over-the-counter antihistamine like Benadryl.

What does tattoo poisoning look like? ›

When these markers come into contact with your skin, mild irritation can occur. Symptoms include redness, swelling, and itchiness. Also, permanent marker fumes can be irritating to your eyes, nose, and throat.

How many days tattoo swelling last? ›

It is normal for a tattoo to be red, swollen, and tender for the first 48 to 72 hours. There may also be some oozing of blood and/or ink during this time period.

How much do you tip a tattoo artist? ›

“A suggested percentage of 20% to 25% for personal services is an accepted standard, especially in these post-COVID times.” Cornolo puts the range between 15% to 20%, but says that it really varies. “Some tip less, and some are very generous."

How long should tattoo swelling last? ›

Your new tattoo will be red, irritated, swollen, warm-to-the-touch & possibly bruised; this is all NORMAL. This will normally last 1 to 3 days. If your tattoo is on an extremity, especially below the knee, you may experience more swelling than normal.

What cream is good for inflammation? ›

Voltaren (diclofenac) gel, capsaicin cream, and menthol cream are common topical anti-inflammatory medications. When used as directed, anti-inflammatory creams can have similar benefits as their oral counterparts. They also tend to have fewer side effects.

Can you put anti-inflammatory cream on tattoo? ›

Aquaphor is a commonly recommended part of a tattoo aftercare regimen. It has hydrating and anti-inflammatory properties that can speed healing and make the process more comfortable. If you're getting some new ink, or have just gotten a tattoo, you may want to consider using Aquaphor.

How long do you ice a tattoo? ›

Once you get home and settled in, it's recommended that the tattooed area be iced for approximately 20 minutes. As you start this soothing process, you will notice: Swelling will start to go down. Bruising will be reduced because the icing temporarily decreases the amount of blood flow to the sore area.

Can I get my money back for a tattoo? ›

Any decent tattooist will be happy to do so. If they refuse, walk away. However, if you're not happy with the result then you should talk to the studio and explain what your issue with the design is. They may agree to offer you a refund or work on the tattoo to bring it up to your expectations at no extra cost.

How do I sue for an allergic reaction? ›

If you want to sue for an allergic reaction, you would need evidence to prove that someone's negligence, for example, a restaurant, has caused your allergic reaction. If you don't have evidence, then your claim for compensation for an allergic reaction would be unlikely to succeed.

Can you have an anaphylactic reaction to tattoo ink? ›

Tattoos are increasingly prevalent in Western society. Delayed-hypersensitivity reactions to tattoo ink are well described in the literature, but, to our knowledge, anaphylaxis after permanent tattoos has never been reported.

Are tattoo allergies treatable? ›

Tattoo allergies are often eczematous skin rashes that can be complicated by ulceration and infection. These allergies are difficult to resolve, sometimes requiring surgical or laser intervention, with varying success.

What percentage of people are allergic to tattoos? ›

More than 10% of those surveyed reported experiencing an adverse reaction to the tattoo, such as itching, swelling or a rash. About 6% experienced a chronic reaction lasting longer than four months. “I've seen quite a few of these reactions,” says Douglas Powell, MD, a dermatologist at University of Utah Health.

How many people have allergic reactions to tattoos? ›

Overall, 38 543 individuals were patch-tested during the study period; 29 (0.08%) had tattoo-related ACD (Table I). Two thirds were female, and most were young adults (ages 19-39 years).

Can you put hydrocortisone cream on tattoo rash? ›

The tattoo should peel like a sunburn and will begin to itch as the skin repairs itself. If you experience severe itching you can use hydrocortisone 1% anti-itch cream (available at any drug store or supermarket) to help control the itch.

Why is my tattoo suddenly raised and itchy? ›

One of the most common problems associated with tattooing is allergic reactions to the tattoo pigments. Itching, bumps or rashes can occur days, months or even years after the initial tattoo. These reactions need to be treated with a topical steroid ointment.

Is my tattoo infected or just swollen? ›

If you begin to feel feverish and experience abnormal oozing or scabbing around the tattooed area, see a doctor. These are common signs of infection. You should also see a doctor if a rash or swelling lasts for more than a week.

What are the first signs of an infected tattoo? ›

Signs of an infected tattoo
  • Worsening red, itchy bumps at the tattoo site.
  • Redness and swelling: remember that mild redness is to be expected the first two to three days after getting a tattoo. ...
  • Pus with foul-smelling drainage.
  • Worsening pain.
  • Systemic symptoms like fevers and chills.
Jul 25, 2022

Can I put Neosporin on an infected tattoo? ›

Using Neosporin on an infected tattoo is not recommended. Neosporin is an over-the-counter antibiotic ointment that is commonly used to treat minor cuts and abrasions, but it may not be effective in treating a tattoo infection.

How long should there be redness around a new tattoo? ›

All tattoos will be somewhat red for a few days after the procedure, but if the redness doesn't subside, it's a sign that your tattoo isn't healing well. Oozing fluid. If fluid or pus is still coming out from your tattoo after 2 or 3 days, it may be infected. See a doctor.

Why is my new tattoo red and irritated? ›

New tattoos always cause some irritation. Injecting ink-covered needles into your skin spurs your immune system into action, resulting in redness, swelling, and warmth. These symptoms should fade once your skin cells adjust to ink. A rash, on the other hand, can develop at any time.

Why is my tattoo hot and swollen? ›

If you've got a bit of tattoo bruising or tattoo swelling, it's just a sign that your body is healing by sending more blood to the affected area, it's not usually anything to worry about and it's very rare to have an allergic reaction. If you're concerned, go and see a doctor to put your mind at ease.

Do tattoos cause permanent inflammation? ›

Tattoo pigment can precipitate many inflammatory states. The skin is the most common site of inflammation, but tattoo ink can become disseminated and cause systemic inflammation. Granulomatous reactions are a rare type of tattoo reaction, often caused by black tattoo ink, and are challenging to manage.

Can I put cortizone 10 on my tattoo? ›

OTC creams and ointments

As a rule of thumb, you don't want to apply over-the-counter (OTC) creams and ointments to new tattoos because these can interfere with your skin's natural healing process. You can, however, apply topical hydrocortisone to an itchy, older tattoo.

What is good for allergic reaction for tattoo? ›

If you're having an allergic reaction to your tattoo, you might get a rash that's red, bumpy, or itchy. These symptoms can crop up in the days after you first get your tattoo or can appear months or years later. You can most likely treat the area with a steroid ointment.

Does Benadryl help with tattoo swelling? ›

You may take an antihistamine (Benadryl, Claritin, Allegra, Zyrtec, etc.) if needed for swelling or itching at treatment site. Please check with your Laser Specialist before taking medication if you have questions. Mild swelling, redness, tenderness is normal for about 1 week.

How do you treat an allergic reaction to Saniderm? ›

If you develop a rash, skin irritation, or other signs of an allergic reaction, immediately remove your Saniderm and wash the area with mild soap, then immediately discontinue the use. Saniderm should not be used on infected skin. Consult a physician if necessary.

Should I take Benadryl after a tattoo? ›

For intense itching, washing and reapplying your moisture product may help – if not, consider taking an over-the-counter antihistamine like Benadryl.


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