By Ramana S. Moorthy, MD, FACS
This study reports on seven patients in whom a component of tattoo pigment initiated a localized cutaneous response that played a role in the simultaneous development of ocular inflammation.
This paper highlights that practicing ophthalmologists should be aware of the association of tattoo induration and ocular inflammatory disease and its potential relationship to systemic sarcoidosis. As the authors state, long-term follow-up is necessary to determine if other organs, in addition to the skin and eyes, also become affected by granulomatous inflammation.
They reviewed the charts of seven consecutive patients who presented to a tertiary ophthalmologic facility (Wilmer Eye Institute) over an 18-month period with uveitis and coincident onset of raised and indurated tattooed skin. None of the patients had a prior diagnosis of sarcoidosis. The mean follow-up was nine months. Six patients were African American and five were male. They ranged in age from 20 to 42 years.
At presentation, five had bilateral nongranulomatous anterior uveitis and two had granulomatous panuveitis. One had recurrent disease while the rest had chronic persistent disease. None had an abnormal cutaneous reaction immediately after tattooing, and all had the most recent tattooing placed at least six months prior to the onset of cutaneous and intraocular symptoms. Five had extensive tattoos containing only black pigment or multicolored tattoos containing black ink. The other two patients had more limited tattooing.
Interestingly, in all seven patients, only the tattoos that contained black pigment were affected. All or some portion of the tattoos were indurated when inflamed. Tattoo biopsy in two patients revealed noncaseating granulomas with histiocytes surrounding black tattoo pigment in the dermis. At least five of the patients had vision-threatening complications of intraocular inflammation, including iris bombe, pupillary membrane, cystoid macular edema and glaucoma.
All patients showed improvement in ocular inflammation and simultaneous resolution of tattoo induration after treatment with high-dose systemic corticosteroid therapy. Three patients required systemic immunomodulatory therapy.
The histopathologic differentiation between foreign body and sarcoid granulomatous inflammation can be challenging and controversial. Prior to this report, allergic reactions to black tattoo pigment have been very rare although it is thought that allergic reactions to specific components of tattoo pigment may represent a manifestation of systemic sarcoidosis. Black tattoo ink is thought to contain toxic immunogenic or carcinogenic compounds, such as carbon black and polycyclic aromatic hydrocarbons or phenol.
I found these case reports to be particularly interesting and clinically relevant. I currently have at least three active patients with tattoo-associated bilateral granulomatous panuveitis that appears to be consistent with sarcoidosis. I have managed these patients in a similar fashion as the authors. Tattoo biopsy of one of my patients revealed granulomatous inflammation of the skin. It is possible that tattoo ink may provide some clues as to the underlying environmental antigen that may trigger granulomatous inflammation in genetically predisposed individuals.
The authors failed to mention that granuloma annulare is a condition that can present without tattooing where there is granulomatous sarcoid-like inflammation of the skin. This condition also has been associated with chronic uveitis. Several of the patients in this case series developed chronic inflammation that was recalcitrant to corticosteroid therapy alone and required immunomodulatory therapy. This is typical of the patients that I have seen as well.