Allergol et Immunopathol 1999;27:32-33.
Urticaria in a tattooed patient
G. F. Bagnato, R. De Pasquale, O. Giacobbe, G. Chirico, L. Ricciardi*, S. Gangemi* and F. Purello D''Ambrosio*
Department Internal Medicine. University of Messina. Italy. *School of Allergology and Clinical Immunology. University of Messina. Italy.
SUMMARY
We present a case of urticaria in a tattooed patient due to hypersensitivity to the cobalt chloride contained in the blue ink used for tattoo. The patch test with the series of International Contact Dermatitis Research Group was positive only for chloride cobalt. Cobalt is believed to be responsible for contact urticaria through a non-immunological mechanism.
On reviewing the literature we have found no report of contact urticaria to cobalt in tattooed patients.
Key words: Tattoo. Cobalt. Urticaria. Patch-test.
RESUMEN
Presentamos un caso de urticaria en un paciente tatuado que se produjo por hipersensibilidad al cloruro de cobalto del colorante azul utilizado para el tatuaje. Las pruebas cutáneas hechas con la serie del Grupo de Investigación Internacional de Dermatitis por Contacto fueron positivas únicamente para el cloruro de cobalto. Se cree que el cobalto puede producir urticaria de contacto mediante un mecanismo no inmunológico.
Al revisar la literatura no encontramos ninguna comunicación de urticaria de contacto producida por el cobalto en pacientes con tatuajes.
Palabras clave: Tatuaje. Urticaria. Cobalto. Pruebas cutáneas.
INTRODUCTION
Tattooing designs and symbols on the skin is a very ancient practice and holds different meanings in various civilizations. It should be carried out by specialized personnel who inject colored ink into the skin using electric needles. The ink contains a great variety of insoluble coloured pigments (1). The most important substances used are: mercury sulphate for the red color; cobalt alluminate (COAL203) for light blue; chronic oxide for green; cadmium sulfate for yellow; ferrous oxide for brown and carbon for dark blue (1).
Alfter tattooing, the normal reaction is edema, inflammation, exudate and a scab form, which usually disappears after 3 weeks (1, 2). Some persistent or late reactions have been noted, but considering the great quantity of tatoos carried out, these are somewhat rare (1).
Secondary reactions may be either caused by various infections transmitted during application of by deposits of materials which the human skin considers foreign substances.
The latter case leads to three kinds of reactions:
a) development of lower resistance or alterations of the skin with psoriasis, lupus erythematosous and lichen planus;
b) development of an antibody-type reaction due to the presence of a foreign substante, e. g. sarcoidosis;
c) development of hypersensitivity towards one or more of the colored pigments injected (3).
Verrucas, reticolosarcomas and melanomas (4) have also been found at the side of tattoos. The histological examination shows several alterations mainly involving the skin, but the epidermis has also undergone alterations such as acantosis or spongiosis (4).
In literature hypersensitivity reactions towards particular pigments used in tattooing are reported.
These reactions, like the lichenoid ones, are more frequent when red inks are used, derived from mercury sulfate (1, 5, 6), whereas only few cases of allergy have been describe towards green and blue, therefore to chromium and more to aluminum or chloride cobalt (7-11).
CASE REPORT
A 42 years-old male, with no personal or family history of atopy, presented clinical features of widespread urticaria. Corticosteroids and H1-antagonists had provided only temporary relief. Routine biochemical data were normal. The patient reported that the urticarial symptoms had appeard 2 months after he had been tattooed on the deltoid region of his right arm.
The tattoo was blue and its size roughly 10 x 6 cm (Fig. 1). A 72-h patch test was carried out with the routine series of the International Contact Dermatitis Research Group and revealed marked sensitivity (+++) to cobalt chloride. A 48-h application of the blue ink used for the tattoo to the patient''s forearm was also positive and provoked a crop of dyshidrotic vesicles, preceded by erythema and itching.
Figure 1.--Blue tatoo on the deltoid region of the right arm.
The histological examination of the tattooed skin biopsy showed vascular dermis edema and perivascular infiltration, consisting of lymphocytes, histocytes and few eosinophil granulocytes.
The urticarial symptoms ceased short time after the surgical removal of the tattoo.
DISCUSSION
Pathological reactions to tattoos have been described, such as to blue pigments due to hypersensitivity to cobalt (5, 9, 11).
These reactions are usually associated to an allergy to nickel, and are frequent in Europe but not in the USA (2). Cobalt is believed to be responsible for contact urticaria through a non-immunological mechanism. Chemical mediators are released, such as histamine, prostaglandines, leukotrienes and other inflammatory mediators, without any antibodies involved. The profusion of eosinophilic cells in the infiltrate suggests an allergic response.
An allergic reaction to the light-blue pigments, due to hypersensitivity to cobalt, has been described by Bjornerg (9).
The short interval between the application of the tattoo and the onset of symptoms and the positivity to cobalt chloride lead us to conclude that the urticaria was triggered by the tattoo. This hypothesis was confirmed as the urticarial symptoms ceased after the surgical removal of the tattoo.
The case reported appears to be important as tattooing could explain some cases of so-called idiopatic urticaria since it is becoming so popular.
It would also be advisable to suggest undergoing allergological tests in tattooed patients with urticaria clinical features.
REFERENCES
1. Verdich J. Granulomaticus reaction in a red tattoo. Acta Derm Venereol 1981;61:176-7.
2. Madden S. Reactions in tattoos. Arch Dermatol Syph 1939;40:256.
3. Rostemberg A Jr, et al. Discussion of tattoo reactions with report of a case showing a reaction to a green colour. Arch Derm Chicago 1950;62:540-7.
4. Sowden JM, et al. Read tattoo reactions: x-ray microanalisis and patch test studies. British Journal of Dermatology 1991;124:576-80.
5. Bendsoe N, et al. Inflammatory reactions from organic pigments in red tattoos. Acta Derm Venereol (Stockh) 1991;71:70-3.
6. Winkelmann RK, et al. Lichenoid delayed hypersensitivity reactions in tattoos. Journal of Cutaneous Pathology 1979;6: 59-65.
7. Tazelaar RK, et al. Hypersensitivity of Chronium in a light-blue tattoo. Dermatologica 1970;141:282-7.
8. Bjornerg A. Allergic reaction to chrome in green tattoo markings. Acta Dermato Venereologica 1959;39:23-9.
9. Bjornerg A. Allergic reaction to cobalt in light-blue tattoo markings. Acta Dermato Venereologica 1961;41:259.
10. Loewental LJA. Reactions in green tattoos. Arch Dermatol 1960;82:129.
11. Smith D, James D, et al. Contact urticaria from cobalt chloride. Arch Dermatol 1975;3:1610-1.
Correspondence:
Prof. G. F. Bagnato
Policlinico Universitario - Dip. Medicina Interna
Via Console Valeria 2 Messina - 98100 Italy
