Surgical Excision and Reconstruction of Tattoo Following Hypersensitivity

Sammy Othman, MD; Omar Elfanagely, MD; Kevin Klifto, DO, PharmD; Cody Fowler, BS; Douglas J Pugliese, MD, MPH; Stephen J Kovach, MD


ePlasty. 2022;22(e15) 

In This Article

Abstract and Introduction


Background: Hypersensitivity reaction in a tattoo secondary to red ink is a relatively rare complication, particularly as the biochemical composition of tattoo dye has been refined. Most hypersensitivity reactions are amenable to conservative management, but less common is the necessity for full surgical excision and reconstruction.

Methods: A 50-year-old female patient with a chronic tattoo granuloma causing excessive pruritus, erythema, and ulceration, refractory to conservative and minimally invasive techniques, underwent full surgical excision and skin-graft reconstruction of the areas affected by the red dye. Additionally, literature was reviewed for similar reports requiring excision.

Results: The patient reports complete symptomatic resolution and satisfaction with the result. The literature reveals a small set of cases reporting a necessity for surgical excision following red-ink hypersensitivity.

Conclusions: Tattoo hypersensitivity secondary to a red ink–induced allergic reaction is relatively rare. Most cases are amenable to conservative treatment; however, surgical excision and reconstruction provides a viable option in cases refractory to traditional and less invasive management.


Tattoos have long been a historic multicultural form of artistic expression and have only become more frequent and popular as time has passed. As techniques and creativity have evolved, so too has the understanding of safe and efficacious practices that help maximize aestheticism and minimize complications. In the modern world, tattoos are generally performed by an oscillating needle that penetrates the skin and deposits ink particles largely composed of hydrocarbons and water within the papillary dermis.[1] This begins by loading the needle with the desired ink composition, where then the oscillation occurs within the skin at nearly 200 beats per second. The skin then commences wound healing in the traditional stages of hemostasis, proliferation, and remodeling, resulting in collagen deposition and fibrosis to increase the permanency of the particles and tattoo.[1,2] Although the technique has been refined, despite these efforts, some individuals may suffer from undue side effects, including those with inflammatory, neoplastic, and infectious pathology.[1]

Inflammatory reactions are sometimes a result of the tattoo ink itself, which may contain haptens that can beget immunological reactions.[2] These have been previously reported as causes of delayed hypersensitivity, lichenoid, and granulomatosis reactions.[2,3] Red pigment in particular has been implicated as a potential cause of hypersensitivity reaction formation. This, however, cannot be attributed to one substance because several varying biochemicals and heavy metals are used to create and comprise red tattoo ink, and several of these have been reported to precipitate these reactions. These include mercury in the form of cinnabar, zirconium, ferric hydrate, and cadmium, amongst others.[2,4,5] Symptoms may vary in intensity and severity, and patients may suffer from acute or chronic erythema, edema, pruritus, nodule formation, ulceration, and, rarely, progress to systemic allergic reactions.[2]

Fortunately, many cases can be resolved with conservative treatments. Topical and intralesional corticosteroids are frequently employed with good success. In less responsive cases, laser removal for nonallergic reactions and superficial excision using dermatome shaving may be required.[6,7] Less frequently reported is the necessity for complete excision and reconstruction, particularly in the setting of red ink–induced foreign body reactions. Presented here are a patient necessitating complete tattoo excision and reconstruction secondary to a chronic hypersensitivity reaction refractory to less invasive methods and a review of the literature for prior cases of patients requiring tattoo excision following red ink dye allergic reactions.