Page 111 - Journal of Special Operations Medicine - Summer 2016

tattoo acquired on her chest. She was prescribed a 10- A punch biopsy sample was obtained, and routine he-
day course of topical clindamycin with no subsequent matoxylin and eosin staining revealed findings consis-
improvement; the pain and mild pruritus persisted, thus tent with a hypertrophic scar/early keloid formation.
causing her to see her primary care provider. We suggested treating the lesion as an early keloid with
ILK injections. The patient was also counseled that an
At her primary care visit, the patient denied significant infection not detected on routine staining (i.e., atypical
medical history, drug allergies, and previous keloid or mycobacteria) may still be causative, especially if the
hypertrophic scar formation with prior tattoos or skin patient noted worsening with ILK. The patient wanted
piercings. She had obtained a red-pigmented tattoo on to continue with scheduled ILK injections every 4 to
her foot 18 months earlier with no adverse reaction. Im- 6 weeks and was additionally instructed to follow up
mediately after returning from deployment in September sooner if the lesion developed increased tenderness, ery-
2014, she obtained a left chest and back tattoo, both of thema, or new discharge; such symptoms would prompt
which healed appropriately. To treat the symptoms of additional biopsy at that time with a specific section for
her right chest tattoo, her primary provider prescribed acid-fast bacilli (AFB) staining and culture if possible.
a 10-day course of doxycycline, cefuroxime, and pro- Four weeks later, the patient’s symptoms had improved
biotics, with instructions to follow up in 2 weeks if no with reduction in the size of the plaques and papules af-
improvement was seen. ter ILK treatment. At subsequent visits, the dose of ILK
has been increased to 20mg/mL, which has markedly
During the subsequent 2 weeks after her primary care reduced her symptoms (Figure 1B and 1C).
visit (now 8 weeks from initial acquisition of the right
chest tattoo), the patient’s pain and pruritus continued Discussion
to increase and she developed worsening inflammation
and edema. As the course of doxycycline and cefurox- Tattooing is associated with multiple health risks. In the
ime yielded suboptimal improvement, topical fluoci- military population, acquiring tattoos is a common ven-
nonide 0.05% cream was added. However, the cream ture, but it is not without risks of infection and other
did not improve symptoms, prompting a referral to subsequent complications about which providers can
dermatology. counsel patients. The literature lacks the exact incidence
of health dangers associated with tattoos. It is believed
Focused dermatologic examination revealed a red-and- that this lack of data is not a product of infrequency
black butterfly-shaped tattoo over the right upper chest of complications but rather a result of infrequent re-
with tender plaque and papules noted mostly within the porting in the literature or to state health departments.
2
red tattoo pigment (Figure 1A). Concern for infection Localized infection is the most common complication,
persisted despite her minimal response to recent anti- particularly with newly acquired tattoos, due to a tem-
biotic course. As she had been deployed just 3 months porary reduction in skin integrity. A Centers for Dis-
3
earlier and was routinely placed in proximity with Ser- ease Control and Prevention (CDC) report found that of
vicemembers returning from deployment to the Middle 34 methicillin-resistant Staphylococcus aureus (MRSA)
East, another consideration included an atypical my- cases studied, 10 cases were due to secondary exposure
cobacterial infection. Additional concerns included a that was defined as living in the same house or having
foreign body granuloma, allergy to the red ink, a granu- close personal contact. Additionally, although the tat-
lomatous reaction secondary to underlying sarcoidosis, too businesses reported their artists wore gloves and
or—most benign—a hypertrophic scar formation. practiced other infection control measures to include

Figure 1 (A) Painful plaques and papules noted in areas of primarily red ink. (B, C) Reduction in plaque and papule formation
after treatment with ILK.
(A) (B) (C)

Lesions Arising in a Tattoo 97