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Decorative tattooing is associated with a number of complications, and pseudolymphoma is an unusual and difficult problem. We report a case of pseudolymphoma caused by a tattoo that was not treated with potent topical and intralesional steroids. She responded well to sequential treatment with ablative fractional resurfacing (AFR) followed by a QS modulated Nd:YAG 532 nm laser. Interestingly, we were able to document the removal of her tattoo pigments after laser treatment for histology, and we would like to highlight the use of special dyes, such as Grocott methenamine silver (GMS) staining, as a useful method for assessing the presence of tattoo pigment in certain cases. where dense inflammatory infiltrates are present.
Entry
Tattooing is associated with many complications, while pseudolymphoma, limited to the area of the tattoo, is rare and difficult to treat. We report a case of pseudolymphoma caused by a tattoo, which was treated sequentially with ablative fractional resurfacing (AFR) followed by Q-switched (QS) Nd: YAG 532 nm laser. It is interesting that our case has a histology that confirms the removal of the offending tattoo pigment in the areas treated with a laser, which confirms that the consistent use of lasers effectively removes pigments.
Case report
A 45-year-old Chinese woman developed itchy nodules bordered by red areas of her tattoo above her left ankle 4 months after the tattoo was applied by a professional artist. The tattoo was in the form of a red heart with two black eyes. During physical examination, erythematous nodules were found on the red part of the tattoo, some of which merged into plaques.
Initial differences included allergic contact dermatitis to red dye, granulomatous reactions secondary to a foreign body, sarcoidosis, or infection. Histology revealed an upper lymphocytic infiltrate with numerous eosinophils inside. Dark red non-polarizable exogenous pigment was scattered throughout the dermis. Immunohistochemical staining showed an infiltrate mainly of T-cells with a cluster of differentiation (CD) 4: CD8 with a ratio of 4: 1. A few aggregates of CD20-positive B-cells were mixed with the infiltrate. Cultures of fungi and mycobacteria were negative.
On the basis of clinical and pathological data, a diagnosis was made: pseudolymphoma caused by a tattoo. The reaction did not respond to clobetasol propionate 0,05% United States Pharmacopoeia (USP) ointment and triamcinolone acetonide 10 mg/ml intralesional. She received laser treatment monthly for three sessions with good improvement and reduction of swelling and pigmentation. The parameters used included power: 30 W, delay time: 1500 µs, intelligent stack 1, pitch: 500 µm.
Then she had three sessions Q-modulated Nd: YAG laser (QS) monthly with the following parameters: red tattoo - 532 nm, spot size 3 mm, fluence between 2 J / cm 2 and 3 J / cm 2. 1064 nm was applied to the black tattoo, spot size 4 mm, energy density of 8 J / cm 2 to 10 J / cm 2.
The patient preferred to remove the final black pigments, and an elliptical excision specimen was made of both "eyes", which also included the adjacent skin that had been treated from the red pigmentation of the tattoo. Histology revealed epidermal spongiosis and reactive lymphoid hyperplasia with eosinophils, scar tissue, and the final exogenous black tattoo pigment. However, there was no final red tattoo pigment on the areas treated with red pigment tattoos. Grocott Methenamine Silver (GMS) staining was used because lymphocytes and eosinophils take on the color of the special stain (green in GMS) and thus are not visualized, while the red tattoo pigment retains its red color, thus allowing the red tattoo to be considered exogenous pigment
Discussion of the results
Pseudolymphoma caused by a tattoo is a rare disease, at the moment about 20 cases have been registered. It mainly affects the red color component due to mercury sulfide. Pseudolymphomas usually represent a combination of T-cells and B-cells. Immunohistochemical staining and rearrangement of the T-cell receptor gene can be performed to rule out malignant lymphoma. The proliferation of lymphocytes can be caused by an immunogenic pigment, which leads to sensitization and the development of a delayed-type hypersensitivity reaction.
Clinical differences include allergic contact dermatitis to red dye, lichenoid or granulomatous reactions from tattoos, as well as skin infections such as atypical mycobacterial and deep fungal infections. Patch testing would be useful for evaluating allergic contact dermatitis, but it was not performed in our patient. Histology played an important role in making the final diagnosis, which was additionally confirmed by the disappearance of tattoo pigments on histological slides after laser treatment.
Managing this state is a difficult task. Progression of pseudolymphoma into obvious skin lymphomas can be caused by persistent antigenic stimulation by tattoo pigments. Removal of the harmful antigen by simple excision is curative, but not always possible. Effective treatment has been reported only with potent topical and/or intralesional corticosteroids, which was not the case in our patient.
Various lasers were used on the basis that stopping the antigenic stimulus by removing the pigment will lead to the resolution of pseudolymphoma. A combination of AFR and QS 532 nm Nd:Yag lasers has been reported for tattoo removal with mixed results due to incomplete pigment removal. AFR uses laser microbeams to form an array of very small deep tissue removal zones with intervening areas of normal skin. It is assumed that part of the tattoo is physically removed with each treatment. The creation of microscopic channels makes it possible to displace tattoo pigments. It is postulated that QS lasers remove tattoo pigments by means of transepidermal removal, lymphatic channels, and rephagocytosis. The paradoxical darkening of tattoos containing red pigments is associated with the reduction of iron oxide (Fe 3+) to iron oxide pigment (Fe 2+). Our patient reported darkening of the tattoo after the first QS laser session, which improved with subsequent sessions. Generalized allergic reactions after lasers caused by the release of antigenic ink particles into the hematological or lymphatic system are rarely reported. There have been reports of the use of ablative fractional resurfacing for the treatment of tattoo allergy without progression to systemic hypersensitivity. Our patient did not receive prior treatment with antihistamines or systemic corticosteroids and remained in good health during laser treatment.
In the literature, QS lasers are first used, and then AFR. It was hypothesized that the strong inflammatory and phagocytic phases induced by AFR will contribute to the removal of tattoo pigments treated with the QS laser. AFR prevents the formation of bubbles after the QS laser, allowing the release of liquid through the ablation zones. This helps with removal of pigment, faster healing and reduction of hypopigmentation. However, in our case we performed 3 sessions of AFR before 3 sessions of QS lasers with good results. After the inflammatory reaction disappeared with the AFR treatment, the main focus was on removing the final tattoo with the standard QS laser. The final result in our case was excellent, and the inflammatory reaction did not recur within 12 months after treatment.
From a histological point of view, the presence of a dense infiltrate of lymphocytes and eosinophils made it difficult to visualize the red pigment of the tattoo with standard staining with hematoxylin and eosin. We have found that the use of special dyes, such as GMS staining, is a simple and useful method for assessing the absence or presence of tattoo pigment, and we recommend the use of such special dyes to visualize exogenous pigment in cases where there is a dense inflammatory infiltrate, as in our case .
Thus, we report a case of pseudolymphoma developing in the red color of a tattoo that was successfully treated with sequential use of AFR followed by QS 532 nm Nd:YAG laser. Combined laser therapy for this rare and difficult-to-treat complication of tattooing can enhance conventional treatment with corticosteroids, eliminating antigenic stimuli and suppressing the excessive inflammatory response.
