Acta Dermato-Venereologica 98-4CompleteContent | Page 20

458 SHORT COMMUNICATION Sarcoidal Foreign Body Reaction as a Severe Side-effect to Permanent Makeup: Successful Treatment with Intralesional Triamcinolone Jörg TITTELBACH, Melanie PECKRUHN, Sibylle SCHLIEMANN and Peter ELSNER Department of Dermatology, University Hospital Jena, Erfurter Straße 35, DE-07743 Jena, Germany. E-mail: [email protected] Accepted Dec 20, 2017; Epub ahead of print Dec 21, 2017 Permanent makeup is a type of cosmetic tattoo in which micropigments are frequently used. The procedure is advertised as “harmless and safe” and the cosmeticians who perform it do not need any formal approval. None­ theless, there is a broad spectrum of possible side-effects associated with permanent makeup, the most frequent being infections, and pigmentation of the surrounding area by lymphatic drainage of pigments or local inflam- mation (1, 2). Histological patterns of inflammatory reactions are non-specific. They may resemble acute contact dermatitis, chronic eczema, lichenoid dermatitis, lupus-like patterns or granulomatous, including foreign body and sarcoidal, reactions (3). A granulomatous reac- tion following tattooing may also indicate sarcoidosis (4, 5). Treatment of inflammatory side-effects of permanent makeup can be challenging, due to deep deposition of the pigments. Patients must be informed about possible severe risks prior tattooing. CASE REPORT On initial presentation in our outpatient clinic, a 41-year- old woman reported having had permanent makeup 10 years previously, which had been refreshed after 5 years. She had noticed itchy red papules developing in the tattooed area, starting on one side, 18 months previously. Dermatological treatment with silicone scar gel, followed by mometasone cream, did not result in sufficient improvement. Therefore, a biopsy had been taken, which revealed a “granulomatous foreign body reaction”. The patient received laser treatment, which resulted in a temporary improvement, but was followed by new, now partially ulcerating, lesions. She then tried self-treatment with aloe-vera-containing gel and panthenol cream. Dermatological examination revealed yellowish-ery- thematous indurated papules with mild scaling accentu- ated on the medial eyebrows (Fig. 1a). Angiotensin-converting enzyme, soluble interleukin- 2-receptor, calcium level, blood sedimentation rate, and blood count were within normal ranges. Mycological testing of skin scales from the eyebrows (native, culture, and PCR) was negative for dermatophytes. Antinuclear antibodies were negative. Chest X-ray was without patho­logical findings. Patch-tests according to recommendations by the German Contact-Allergy-Group (DKG) including standard, preservatives, ointment bases, hairdresser’s series-substances (6), as well as the patient’s own sub- stances (aloe-vera gel, panthenol ointment, PUREBEAU HiCon Permanent Eyebrow-colour (PUREBEAU New Cosmetics GmbH, Berlin, Germany)) showed positive test results at 72 h only to nickel (II) sulphate (+++) and methylisothiazolinone (++), which were not present in the tattoo material. A skin biopsy showed granulomatous accumulation of epithelioid cells in the whole dermis, surrounded by a sparse lymphocytic infiltrate and some multinuclea- ted histiocytes on dermatopathological investigation. There was no evidence of foreign bodies under polarized light (Fig. 2) and special stains (Fite Faraco and Ziehl- Neelsen) did not reveal the presence of mycobacteria as reported by other authors (7, 8). After the establishment of a diagnosis of a granuloma- tous foreign body reaction of sarcoidal type to tattoo-ink Fig. 1. Clinical photographs before and after therapy. (a) Yellowish-brown-red papules and plaques, that showed an apple-jelly-coloured infiltrate under diascopy. (b) Improvement after 5 injections of triamcinolone; 24 weeks after first injection. doi: 10.2340/00015555-2876 Acta Derm Venereol 2018; 98: 458–459 This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta Journal Compilation © 2018 Acta Dermato-Venereologica.