- Email: [email protected]
Squamous cell carcinoma arising from the follicular occlusion triad
Journal of the American Academy of Dermatology Volume 35, Number 3, Part 1
4. 5. 6. 7. 8. 9. 10. 11.
nous dermatosis with gross reticular pigmentation. Jpn J Dermatol 1971;81:78-91. Teraki Y, Shiohara T, Nagashima M, et al. Pmrigo pigmentosa: role of ICAM-1 in the localization of the eruption. Br J Dermatol 1991;125:360-3. Dijkstra JWE, Bergfeld WF, Taylor JS, et al. Prurigo pigmentosa: A persistent lichenoid reaction to bismuth? Int J Dermatol 1987;26:379-81. Cox NH. Prurigo pigmentosa. Br J Dermatol 1987; 117:121-4. Harms M, M6rot Y, Polla L, et al. Prurigo pigmentosa: 3rd non-Japanese case. Dermatologica 1986;173:202-4. Courtois JM, Dalac S, Collet E, et al. Prurigo pigmentosa. Ann Dermatol Venereol 1992;119:757-9. Degavre B, Guilhou JJ, Guillot B. Prurigo pigmentosa. Ann Dermatol Venereol 1994;121:46-9. Roehr P, Paller AS. A pruritic eruption with reticular pigmentation. Arch Dermatol 1993;129:367, 370. Miyakawa S, Kurihara S, Nishikawa T. Prurigo pigmen-
Brief communications 475 tosaaffecting the forehead. Dermatologica 1984;169:135-7. 12. Yamasaki R, Deldo S, Moriyasu S, et al. Three cases of pmrigo pigmentosa. J Dermatol 1981;8:125-32. 13. Tanii T, Kono T, Katoh J, et al. A case of prurigo pigmentosa considered to be contact allergy to chromium in an acupuncture needle. Acta Derm Venereol (Stockh) 1991; 71:66-7. 14. Sugawara H, Inaba S, Iijima S. Three cases of so-called pmrigo pigmentosa. Jpn J Dermatol 1973;83:111-2. 15. Miyachi Y, Yoshioka A, Horio T, et al. Pmrigo pigmentosa: a possible mechanism of action of sulfonamides. Dermatologica 1986;172:82-8. 16. Tashiro M. Two cases ofprurigo pigmentosaresponsive to minocycline. Hifu 1979;21:77. 17. Liu MT, Wong CK. Prurigo pigmentosa. Dermatology 1994;188:219-21. 18. Aso M, Miyamoto T, Morimura T, et al. Pmrigo pigmentosa treated with minocycline. Br J Dermatol 1989; 120:705-8.
Squamous cell carcinoma arising from the follicular occlusion triad R a y m o n d G. Duffesne, Jr., M D , a John L. Ratz, MD, b W i l m a F. Bergfeld, M D , c and Randall K. Roenigk, M D Providence, Rhode Island; New Orleans, Louisiana;
Cleveland, Ohio, and Rochester, Minnesota T h e follicular occlusion triad (FOT) (acne conglobata, hidradenitis s u p p ~ a t i v a [HS], and perifolliculitis capitis abscendens et suffodiens) has been rarely associated with the development o f squamous cell carcinoma (SCC). 1-21 W e describe a patient in w h o m an S C C developed in an area o f chronic HS of the buttocks.
CASE REPORT A 52-year-old white woman had active HS of the buttocks for 36 years despite treatment with oral antibiotics, oral corticosteroids, isotretinoin, and local therapies. Aggressive surgical and carbon dioxide laser marsupialization performed on the more extensively involved left butrock resulted in clinical improvement. However, continued activity necessitated long-term oral antibiotic and
From the Mohs and Laser Unit, Roger Williams Medical Center, Brown University School of Medicine, Providencea;the Ochsner Clinic, New Orleansb; Department of Dermatology, Cleveland Clinic FoundationC; and the Department of Dermatology, Mayo Medical School, Mayo Clinic Foundation, Rochester.d Reprintrequests: RaymondG. Dufresne,Jr., MD, 50 MandeSt., Providence, RI 02908. J Am Acad Dermatol 1996;35:475-7. Copyright © 1996 by the AmericanAcademyof Dermatology,Inc. 0190-9622/96 $5.00 + 0 16/54/71674
retinoid therapy and intermittent focal marsupialization and drainage. In 1987, a 6 cm exophytic tumor rapidly arose in an area of sinus tracts on the right buttock (Fig. 1). An excisional biopsy specimen revealed a moderately well-differentiated SCC, extending well into the dermis and subcutaneous fat, along the adjacent sinus tracts (Fig. 2). The rumor site was excised by the fresh-tissue Mohs micrographic technique; there was no evidence of residual tumor. Four months after operation, acute malaise, edema of the right leg, inguinal adenopathy with ulceration, and multiple new nodular and ulcerated masses in the perianal region developed. Biopsy specimens of the new masses and inguinal nodes demonstrated SCC. Findings from a chest roentgenogram and a chest/abdominal computed tomographic scan revealed pulmonary infiltrate and a hilar nodule, liver metastasis, and right femoral vein thrombosis. Increased uptake in the lumbar spine was noted on a bone scan. Chemotherapy was initiated with cis-platin and 5-fluorouracil. This resulted in a brief decrease in the tumor size. The second cycle of chemotherapy was ineffective, and her condition rapidly deteriorated. The patient died of widespread metastasis 7 months after diagnosis of SCC.
DISCUSSION S C C arising in the F O T has been reported in 30 cases. 1-21 In the majority o f patients, the S C C devel-
476
Brief communications
Fig. 1. Right buttock with exophytic mass.
ops during middle age, with the FOT active since the teenage years. There have been two reports of two family members with the FOT in whom SCC developed. 17, 19 The majority of reported tumors (21 cases) occurred in the buttocks and perianal or sacrococcygeal areas. The risk of SCC in the FOT is unknown. The perianal area appears to be at special risk. In one small series, SCC occurred in up to 3.2% of patients with chronic gluteal/perianal HS. 4 Anderson and Dockerty3 described two cases of SCC in 117 patients (1.7%) with perianal HS. Histologic examination showed a weU-differentiated SCC in the majority of cases, but differentiation from benign pseudoepithelomatous hyperplasia can be difficult.5, 11, 12, 17, 18 Clinical judgment must be exercised in the persistent and aggressive reevaluation of cases suspected of being SCC. SCC from FOT behaves aggressively, with local invasion, distant metastasis, and high mortality. The majority of patients were initially treated with excision, but local recurrence of disease was common. Mohs micrographic surgery may be an aid to evaluate the surgical m a r g i n s . 21
Journal of the American Academy of Dermatology September 1996
F i g . 2. Fistulous tract lined with squamous cell carcinoma. (Original magnification xl0.) REFERENCES
1. Hellier FF. Familial case 0f acne vulgaris with lesions suggesting a relationship to acne conglobata. Br J Dermatol 1939;25:109-19. 2. Schiff BL, Kern AB. Carcinoma developing in chronic acne conglobata. Arch Dermatol 1957;75:878-9. 3. Anderson MJ, Dockerty MB. Perianal hidradenitis suppurativa. Dis Colon Rectum 1958;1:23-31. 4. Jackman RJ. Hidradenitis suppurativa: diagnosis and surgical management of perianal manifestations. Proc R Soc Med 1959;52(suppl): 110-2. 5. Donsky HJ, Mendelson CG. Squamous cell carcinoma as a complication of hidradenifis suppurativa. Arch Dermatol 1964;90:488-91. 6. Dillon JS, Spjut HJ. Epidermoid carcinoma occurring in acne conglobata. Ann Sttrg 1964;159:451-5. 7. Humphrey LJ, Playforth H, Leaver UW. Squamous cell carcinoma arising in hidradenifis suppurativum. Arch Dermatol 1969;100:59-62. 8. Gordon SW. Squamous cell carcinoma arising in hidradenitis suppurativa. Plast Reconstr Surg 1977;60:800-1. 9. Clayton DE, Geller M. Fatal polymicrobial meningitis in a patient with epidelinoid carcinoma complicating ache conglobata. Wis Med J 1978;77:543-5. 10. Alexander SJ. Squamous cell carcinoma in chronic hidradenitis suppurativa. Cancer 1979;43:745-8. 11. Johnston WH, Miller TA, Frileck SP. Atypical pseudoepitheliomatous hyperplasia and squamous cell carcinoma in chronic cutaneous sinuses and fistulas. Plast Reconstr Surg 1980;66:395-9.
Jonlilal of the American Academy of Dermatology Volume 35, Number 3, Part 1
12. Curry SS, Gaither DH, King LE Jr. Squamous cell carcinoma arising in dissecting perifolficulitis of the scalp. J Am Acad Dermatol 1981 ;4:673-8. 13. Black SB, Woods JE. Squamous cell carcinoma complicaring hidradenitis supurativa. J Surg Oncol 1982; 19:25-6. 14. Camisa C. Squamous cell carcinoma arising in acne conglobata. Cuffs 1984;33:185-90. 15. Mora RG, Pemiciaro C. Cancer of the skin in blacks. I. A review of 163 black patients with cutaneous squamous cell carcinoma. J Am Acad Dermatol 1981;5:535-43. 16. Sparks MK, Kuhlman DS, Prieto A, et al. Hypercalcemia in association with cutaneous squamous cell carcinoma. Arch Dermatol 1985;121:243-6. 17. Quintal D, Jackson R. Aggressive squamous cell carcino-
Brief communications 477
18. 19. 20. 21.
mas arising in familial acne conglobata. J Am Acad Dermatol 1986;14:207-14. ZacharyLS, RobsonMC, RachmaninoffN. Squamous cell carcinoma occurring in hidradenitis suppurativa. Ann Plast Surg 1987;18:71-3. Whipp MJ, Harrington CI, Dundas S. Fatal squamous cell carcinoma associated with acne conglobata in a father and daughter. Br J Dermatol 1987;117:389-92. Mendonca H, Rebelo C, Femandes A, et al. Squamous cell carcinoma arising in hidradenitis suppurativa. J Dermatol Surg Oncol 1991;17:830-2. Brown MD, Zachary CB, Greldn RC, et al. Genital tumors: their management by micrographic surgery. J Am Acad Dermatol 1988;18:115-22.
Black tattoo reaction: The peacock's tale Whitney D. Tope, M D , MPhil, a Jack L. Arbiser, M D , PaD, b and L y n M. Dtmcan, M D c
Encinitas, California, and Boston, Massachusetts Tattoo reactions have presumably been k n o w n for thousands o f years. 1,2 Reactions to red, 3-23 purple,24-26 yellow,27, 28 green,12, 20, 29-33andblue20, 34, 35 tattoo pigments have been reported. Reactions to red pigment occur m o s t c o m m o n l y . Histopathologic examination of involved skin frequently shows a lichenoid, nodular, or granulomatous pattern o f inflammation. 21 Occasionally a dense infiltrate merits a diagnosis of pseudolymphoma. 2°, 23 Analytical techniques demonstrate various elements (e.g., mercury, sulfur, cadmium, or selenium) to which a delayed-type hypersensitivity is attributed. 21 The clinical reaction, often a pruritic papular e m p tion, 15, 18, 27, 28 m a y b e p h o t o a c t i v a t e d 15, 18, 21, 24, 27, 32 or occur after exposure to the same elemental antigen 3'3°'31 and m a y be limited to the tattoo or present with a concomitant generalized eruption.7, 9, 13, 17, 30, 31, 34 Tattoo reactions m a y resolve spontaneously, 8 but often persist for months or years despite topical or systemic steroid therapy and m a y finally require surgical excision. W e describe an unusual reaction to black tattoo From DermatologyAssociates of San Diego County, Encinitas,a and the Deparmaentsof Dermatologyb and Pathology,c Massachusetts General Hospitaland HarvardMedical School, Boston. Reprint requests: WhitneyD. Tope,MD, MPhil, Box 98 UMHC,420 Delaware St., SE, Minneapolis,MN 55455-0392. J Am Acad Dermatol 1996;35:477-9. Copyright © 1996 by the AmericanAcademyof Dermatology,Inc. 0190-9622/96 $5.00 + 0 16/54/71676
pigment, presumably simple carbon particles, and a rapid response to topical steroid therapy. N o allergic reactions to black tattoo pigment have been previously reported.
CASE REPORT A 44-year-old white man had inflamed and pruritic tattoos on both arms of 2 weeks' duration. He did not report constitutional symptoms. The patient had no known drag allergies. The four professional tattoos had been placed more than a decade earlier. The tattoo artists who had placed the tattoos were contacted, but were tmable to recall the exact pigments used or the manufacturers. Examination revealed multicolored tattoos on the arms and forearms. Within these tattoos were pink, erythematous, indurated papules discretely localized predominantly to black areas, but also in some red areas. This clinical pattern was best seen in the tail of a peacock tattooed on the patient's right arm (Fig. 1). Nontattooed skin was uninvolved and no adenopathy was present. Biopsy specimens were obtained from papules in both the black and red areas. Each specimen showed noncaseating epithelioid granulomas and pigment-laden dermal macrophages consistent with a foreign body granulomatous reaction to tattoo pigment (Fig. 2). With transillumination and epiillumination of the black and red specimens, both pigments retained their clinically evident colors. To determine the presence of specific elemental constituents, each specimen underwent energy-dispersive x-ray analysis. 36, 37 No atomic spectra above background were noted for the red or black specimens (data not shown).
4. 5. 6. 7. 8. 9. 10. 11.
nous dermatosis with gross reticular pigmentation. Jpn J Dermatol 1971;81:78-91. Teraki Y, Shiohara T, Nagashima M, et al. Pmrigo pigmentosa: role of ICAM-1 in the localization of the eruption. Br J Dermatol 1991;125:360-3. Dijkstra JWE, Bergfeld WF, Taylor JS, et al. Prurigo pigmentosa: A persistent lichenoid reaction to bismuth? Int J Dermatol 1987;26:379-81. Cox NH. Prurigo pigmentosa. Br J Dermatol 1987; 117:121-4. Harms M, M6rot Y, Polla L, et al. Prurigo pigmentosa: 3rd non-Japanese case. Dermatologica 1986;173:202-4. Courtois JM, Dalac S, Collet E, et al. Prurigo pigmentosa. Ann Dermatol Venereol 1992;119:757-9. Degavre B, Guilhou JJ, Guillot B. Prurigo pigmentosa. Ann Dermatol Venereol 1994;121:46-9. Roehr P, Paller AS. A pruritic eruption with reticular pigmentation. Arch Dermatol 1993;129:367, 370. Miyakawa S, Kurihara S, Nishikawa T. Prurigo pigmen-
Brief communications 475 tosaaffecting the forehead. Dermatologica 1984;169:135-7. 12. Yamasaki R, Deldo S, Moriyasu S, et al. Three cases of pmrigo pigmentosa. J Dermatol 1981;8:125-32. 13. Tanii T, Kono T, Katoh J, et al. A case of prurigo pigmentosa considered to be contact allergy to chromium in an acupuncture needle. Acta Derm Venereol (Stockh) 1991; 71:66-7. 14. Sugawara H, Inaba S, Iijima S. Three cases of so-called pmrigo pigmentosa. Jpn J Dermatol 1973;83:111-2. 15. Miyachi Y, Yoshioka A, Horio T, et al. Pmrigo pigmentosa: a possible mechanism of action of sulfonamides. Dermatologica 1986;172:82-8. 16. Tashiro M. Two cases ofprurigo pigmentosaresponsive to minocycline. Hifu 1979;21:77. 17. Liu MT, Wong CK. Prurigo pigmentosa. Dermatology 1994;188:219-21. 18. Aso M, Miyamoto T, Morimura T, et al. Pmrigo pigmentosa treated with minocycline. Br J Dermatol 1989; 120:705-8.
Squamous cell carcinoma arising from the follicular occlusion triad R a y m o n d G. Duffesne, Jr., M D , a John L. Ratz, MD, b W i l m a F. Bergfeld, M D , c and Randall K. Roenigk, M D Providence, Rhode Island; New Orleans, Louisiana;
Cleveland, Ohio, and Rochester, Minnesota T h e follicular occlusion triad (FOT) (acne conglobata, hidradenitis s u p p ~ a t i v a [HS], and perifolliculitis capitis abscendens et suffodiens) has been rarely associated with the development o f squamous cell carcinoma (SCC). 1-21 W e describe a patient in w h o m an S C C developed in an area o f chronic HS of the buttocks.
CASE REPORT A 52-year-old white woman had active HS of the buttocks for 36 years despite treatment with oral antibiotics, oral corticosteroids, isotretinoin, and local therapies. Aggressive surgical and carbon dioxide laser marsupialization performed on the more extensively involved left butrock resulted in clinical improvement. However, continued activity necessitated long-term oral antibiotic and
From the Mohs and Laser Unit, Roger Williams Medical Center, Brown University School of Medicine, Providencea;the Ochsner Clinic, New Orleansb; Department of Dermatology, Cleveland Clinic FoundationC; and the Department of Dermatology, Mayo Medical School, Mayo Clinic Foundation, Rochester.d Reprintrequests: RaymondG. Dufresne,Jr., MD, 50 MandeSt., Providence, RI 02908. J Am Acad Dermatol 1996;35:475-7. Copyright © 1996 by the AmericanAcademyof Dermatology,Inc. 0190-9622/96 $5.00 + 0 16/54/71674
retinoid therapy and intermittent focal marsupialization and drainage. In 1987, a 6 cm exophytic tumor rapidly arose in an area of sinus tracts on the right buttock (Fig. 1). An excisional biopsy specimen revealed a moderately well-differentiated SCC, extending well into the dermis and subcutaneous fat, along the adjacent sinus tracts (Fig. 2). The rumor site was excised by the fresh-tissue Mohs micrographic technique; there was no evidence of residual tumor. Four months after operation, acute malaise, edema of the right leg, inguinal adenopathy with ulceration, and multiple new nodular and ulcerated masses in the perianal region developed. Biopsy specimens of the new masses and inguinal nodes demonstrated SCC. Findings from a chest roentgenogram and a chest/abdominal computed tomographic scan revealed pulmonary infiltrate and a hilar nodule, liver metastasis, and right femoral vein thrombosis. Increased uptake in the lumbar spine was noted on a bone scan. Chemotherapy was initiated with cis-platin and 5-fluorouracil. This resulted in a brief decrease in the tumor size. The second cycle of chemotherapy was ineffective, and her condition rapidly deteriorated. The patient died of widespread metastasis 7 months after diagnosis of SCC.
DISCUSSION S C C arising in the F O T has been reported in 30 cases. 1-21 In the majority o f patients, the S C C devel-
476
Brief communications
Fig. 1. Right buttock with exophytic mass.
ops during middle age, with the FOT active since the teenage years. There have been two reports of two family members with the FOT in whom SCC developed. 17, 19 The majority of reported tumors (21 cases) occurred in the buttocks and perianal or sacrococcygeal areas. The risk of SCC in the FOT is unknown. The perianal area appears to be at special risk. In one small series, SCC occurred in up to 3.2% of patients with chronic gluteal/perianal HS. 4 Anderson and Dockerty3 described two cases of SCC in 117 patients (1.7%) with perianal HS. Histologic examination showed a weU-differentiated SCC in the majority of cases, but differentiation from benign pseudoepithelomatous hyperplasia can be difficult.5, 11, 12, 17, 18 Clinical judgment must be exercised in the persistent and aggressive reevaluation of cases suspected of being SCC. SCC from FOT behaves aggressively, with local invasion, distant metastasis, and high mortality. The majority of patients were initially treated with excision, but local recurrence of disease was common. Mohs micrographic surgery may be an aid to evaluate the surgical m a r g i n s . 21
Journal of the American Academy of Dermatology September 1996
F i g . 2. Fistulous tract lined with squamous cell carcinoma. (Original magnification xl0.) REFERENCES
1. Hellier FF. Familial case 0f acne vulgaris with lesions suggesting a relationship to acne conglobata. Br J Dermatol 1939;25:109-19. 2. Schiff BL, Kern AB. Carcinoma developing in chronic acne conglobata. Arch Dermatol 1957;75:878-9. 3. Anderson MJ, Dockerty MB. Perianal hidradenitis suppurativa. Dis Colon Rectum 1958;1:23-31. 4. Jackman RJ. Hidradenitis suppurativa: diagnosis and surgical management of perianal manifestations. Proc R Soc Med 1959;52(suppl): 110-2. 5. Donsky HJ, Mendelson CG. Squamous cell carcinoma as a complication of hidradenifis suppurativa. Arch Dermatol 1964;90:488-91. 6. Dillon JS, Spjut HJ. Epidermoid carcinoma occurring in acne conglobata. Ann Sttrg 1964;159:451-5. 7. Humphrey LJ, Playforth H, Leaver UW. Squamous cell carcinoma arising in hidradenifis suppurativum. Arch Dermatol 1969;100:59-62. 8. Gordon SW. Squamous cell carcinoma arising in hidradenitis suppurativa. Plast Reconstr Surg 1977;60:800-1. 9. Clayton DE, Geller M. Fatal polymicrobial meningitis in a patient with epidelinoid carcinoma complicating ache conglobata. Wis Med J 1978;77:543-5. 10. Alexander SJ. Squamous cell carcinoma in chronic hidradenitis suppurativa. Cancer 1979;43:745-8. 11. Johnston WH, Miller TA, Frileck SP. Atypical pseudoepitheliomatous hyperplasia and squamous cell carcinoma in chronic cutaneous sinuses and fistulas. Plast Reconstr Surg 1980;66:395-9.
Jonlilal of the American Academy of Dermatology Volume 35, Number 3, Part 1
12. Curry SS, Gaither DH, King LE Jr. Squamous cell carcinoma arising in dissecting perifolficulitis of the scalp. J Am Acad Dermatol 1981 ;4:673-8. 13. Black SB, Woods JE. Squamous cell carcinoma complicaring hidradenitis supurativa. J Surg Oncol 1982; 19:25-6. 14. Camisa C. Squamous cell carcinoma arising in acne conglobata. Cuffs 1984;33:185-90. 15. Mora RG, Pemiciaro C. Cancer of the skin in blacks. I. A review of 163 black patients with cutaneous squamous cell carcinoma. J Am Acad Dermatol 1981;5:535-43. 16. Sparks MK, Kuhlman DS, Prieto A, et al. Hypercalcemia in association with cutaneous squamous cell carcinoma. Arch Dermatol 1985;121:243-6. 17. Quintal D, Jackson R. Aggressive squamous cell carcino-
Brief communications 477
18. 19. 20. 21.
mas arising in familial acne conglobata. J Am Acad Dermatol 1986;14:207-14. ZacharyLS, RobsonMC, RachmaninoffN. Squamous cell carcinoma occurring in hidradenitis suppurativa. Ann Plast Surg 1987;18:71-3. Whipp MJ, Harrington CI, Dundas S. Fatal squamous cell carcinoma associated with acne conglobata in a father and daughter. Br J Dermatol 1987;117:389-92. Mendonca H, Rebelo C, Femandes A, et al. Squamous cell carcinoma arising in hidradenitis suppurativa. J Dermatol Surg Oncol 1991;17:830-2. Brown MD, Zachary CB, Greldn RC, et al. Genital tumors: their management by micrographic surgery. J Am Acad Dermatol 1988;18:115-22.
Black tattoo reaction: The peacock's tale Whitney D. Tope, M D , MPhil, a Jack L. Arbiser, M D , PaD, b and L y n M. Dtmcan, M D c
Encinitas, California, and Boston, Massachusetts Tattoo reactions have presumably been k n o w n for thousands o f years. 1,2 Reactions to red, 3-23 purple,24-26 yellow,27, 28 green,12, 20, 29-33andblue20, 34, 35 tattoo pigments have been reported. Reactions to red pigment occur m o s t c o m m o n l y . Histopathologic examination of involved skin frequently shows a lichenoid, nodular, or granulomatous pattern o f inflammation. 21 Occasionally a dense infiltrate merits a diagnosis of pseudolymphoma. 2°, 23 Analytical techniques demonstrate various elements (e.g., mercury, sulfur, cadmium, or selenium) to which a delayed-type hypersensitivity is attributed. 21 The clinical reaction, often a pruritic papular e m p tion, 15, 18, 27, 28 m a y b e p h o t o a c t i v a t e d 15, 18, 21, 24, 27, 32 or occur after exposure to the same elemental antigen 3'3°'31 and m a y be limited to the tattoo or present with a concomitant generalized eruption.7, 9, 13, 17, 30, 31, 34 Tattoo reactions m a y resolve spontaneously, 8 but often persist for months or years despite topical or systemic steroid therapy and m a y finally require surgical excision. W e describe an unusual reaction to black tattoo From DermatologyAssociates of San Diego County, Encinitas,a and the Deparmaentsof Dermatologyb and Pathology,c Massachusetts General Hospitaland HarvardMedical School, Boston. Reprint requests: WhitneyD. Tope,MD, MPhil, Box 98 UMHC,420 Delaware St., SE, Minneapolis,MN 55455-0392. J Am Acad Dermatol 1996;35:477-9. Copyright © 1996 by the AmericanAcademyof Dermatology,Inc. 0190-9622/96 $5.00 + 0 16/54/71676
pigment, presumably simple carbon particles, and a rapid response to topical steroid therapy. N o allergic reactions to black tattoo pigment have been previously reported.
CASE REPORT A 44-year-old white man had inflamed and pruritic tattoos on both arms of 2 weeks' duration. He did not report constitutional symptoms. The patient had no known drag allergies. The four professional tattoos had been placed more than a decade earlier. The tattoo artists who had placed the tattoos were contacted, but were tmable to recall the exact pigments used or the manufacturers. Examination revealed multicolored tattoos on the arms and forearms. Within these tattoos were pink, erythematous, indurated papules discretely localized predominantly to black areas, but also in some red areas. This clinical pattern was best seen in the tail of a peacock tattooed on the patient's right arm (Fig. 1). Nontattooed skin was uninvolved and no adenopathy was present. Biopsy specimens were obtained from papules in both the black and red areas. Each specimen showed noncaseating epithelioid granulomas and pigment-laden dermal macrophages consistent with a foreign body granulomatous reaction to tattoo pigment (Fig. 2). With transillumination and epiillumination of the black and red specimens, both pigments retained their clinically evident colors. To determine the presence of specific elemental constituents, each specimen underwent energy-dispersive x-ray analysis. 36, 37 No atomic spectra above background were noted for the red or black specimens (data not shown).