Case Study: Managing a Tattoo Complication

By Dr Simran Deo / 01 Jan 2016

Dr Simran Deo shares a case study detailing her experience of using microneedling to treat a hyperpigmented hypertrophic scar following ‘blow-out’ of tattoo ink

With an increasing number of patients undergoing tattoo application, there has been a rise in complications and desire for removal in recent years.1 Tattoo leakage, or ‘blow-out’ occurs if the artist, or applicator, presses too hard, leading to tattoo pigment in the dermis and hypodermis.2 The resultant hyper-inflammatory response can be difficult to treat; however, microneedling provides a promising new modality for treatment.3

Case Study Introduction

A 37-year-old lady of Asian descent (Patient A) was treated for a disfiguring, extensive, inflammatory linear lesion, which descended from the lateral canthus of the right eye to just inferior to the zygomatic arch (Figure 1). In this case, related articles and case studies were reviewed to determine the best treatment modality for Patient A. The patient’s primary concern was overall cosmetic improvement. In treating the patient, we were able to obtain a reasonably successful cosmetic result. The patient said that she had undertaken a semi-permanent makeup tattoo application of her eyebrows 18 months previously. In the week subsequent to this, she had noted a slow descension of pigmentation from her right upper eyelid to the hollow of her right cheek. This scar formation was felt to have occurred due to leakage or ‘blow-out’ of the tattoo pigment. She denied any trauma to the area at the time, and had not recently been pregnant or taken any oral contraceptives, which can worsen hyperpigmentation, or cause melasma.20 There had not been any subsequent pigmentation on the contralateral side of the face, forehead or chin.

More than 60% clinical improvement of scarring was achieved at four weeks

After having previously been advised a diagnosis of melasma, Patient A underwent multiple chemical peels, and used various lightening creams, with little improvement. Treatment had been declined on the NHS, costing the patient thousands of pounds. On inspection, Patient A had an obvious well demarcated, hyperpigmented linear scar running from the lateral canthus of the right eye, over the zygomatic arch and into the hollow of the right cheek (Figure 1). This was most likely a response to residual tattoo pigment. The scar appeared fragmented at the superior aspect, with two well-circumscribed discoid blue/black lesions at the lateral canthus. Dispersing as it travelled inferiorly, it became more red/brown in appearance. The scar appeared raised and shiny, implicating a chronic inflammatory process. The two well circumscribed discoid lesions appeared to contain tattoo pigment. Having maintained a superior skincare regime following the insult, Patient A’s overall skin tone and texture were well maintained for her age, with no evidence of any other hyperpigmentation or scarring.

Consultation

A joint discussion was undertaken with Patient A, exploring her requirements and expectations. Her concerns were purely cosmetic; however, the scar had a significant impact on her quality of life, leading to the commencement of anti-depressants. Patient A was very distressed and tearful, with a Manchester Scar Scale score of 16 out of a maximum of 21.4 Due to the likely presence of tattoo pigment at the lateral canthus, laser treatment could possibly be required at a later stage. It was advised that in order to adequately determine the diagnosis, a biopsy of the lesion should be undertaken; however, the patient declined due to an impending family wedding. Instead, a course of micro needling was advised due to results achieved in previous patients, suggesting sessions be undertaken on a case-by-case basis only, in order to assess improvement and re-assess the management plan at each individual stage

Method

Once informed consent was given by Patient A, EMLA cream was applied. The patient was advised to wait until adequate anaesthesia was achieved, and the skin was cleansed and dried. Using a sterile technique to minimise the risk of infection, the 1.5mm needles were applied at a rate of 100-120 insertions per minute, depending on the location of the scar, with 100 insertions per minute being applied at the lateral canthus, and 120 more inferiorly. The needles were applied to the scar only, with three passes being undertaken on each occasion. 
The surrounding skin remained untouched. Whilst continuing a sterile procedure, any haematogenous fluid produced during treatment, was massaged back into the scar to promote an inflammatory cascade. The area was then cleansed and 1% hydrocortisone was applied, followed by a factor 50 sun protectant in order to avoid any exposure to UVA and UVB rays.

Figure 1: Patient A before microneedling

Figure 2: Patient A, review four weeks after microneedling treatment

Aftercare and maintenance

Following the treatment, the patient was advised to avoid sun exposure, soaps and scrubs and to always wear SPF 50, regardless of the weather. Reviews were arranged four to six weeks after each treatment.

Results

The results on each review were noted and dramatic, with the patient reporting an improvement in her mood and in her ability to apply makeup and camouflage the scar. The treatment response was assessed by comparing pre-treament and four week post-treatment clinical photography. More than 60% clinical improvement of scarring was achieved at four weeks after a single treatment based on independent practitioner assessment. No significant adverse effects were noted. The improvement was persistent at the one month follow-up after each treatment. During the four-week review following the fifth treatment, the resultant Manchester Scar Scale demonstrated significant results, improving from 16 to seven.4

Discussion

Tattooing has become increasingly popular, not only amongst the younger generations, but the older too, leading to a parallel increase in the occurrence of adverse reactions.21 With the ever-increasing incidence of complications due to tattooing, practitioners should be well informed of the possible complications. It is vital that they are able to recognise the signs and symptoms, as well as appropriately counsel their patients on the risks of tattoo application.5 According to literature, the most frequent tattoo-related concerns are allergic contact dermatitis due to a delayed hypersensitivity reaction to tattoo pigments.6,7 The main pigment thought to cause an allergic reaction is red pigment, due to the presence of new organic pigments (pigment red 181 and 170).8 The blue, green, and black pigment are less frequently the cause of allergic contact dermatitis.9-12 Treatment of scars still remains a challenge for most doctors, with scarring being a distressing condition for most patients in the ever-increasing aesthetically aware population. Post-acne scarring, for example, besides causing cosmetic disfigurement, can lead to significant psychological issues if facial scarring is present at a young age.13 Microneedling is safe for use on all skin phototypes14 and for the treatment of scars it is advised that the needle length should be selected considering the depth of the scar present, with a needle length of 1.5mm-2mm being described in many clinical studies.14,15,16 The process relies on an inflammatory cascade and the release of growth factors occurring due to needle insertion into the stratum corneum. It is this formation of micro-channels or micro-wounds in the papillary dermis of the skin that are thought to create a confluent zone of superficial bleeding which acts to stimulate various growth factors, thus stimulating subsequent neocollagenesis and neovascularisation via the process of wound healing. It is these growth factors that are believed to be responsible for the beneficial effects of microneedling in the treatment of scars and photoageing.16,17 Besides acne and post-surgical scars, microneedling has also been used in the treatment of varicella scars and post-herpetic facial scars with good success.3,15

There has, however, been little reported on the impact of micro needling on either chronic inflammatory lesions or on the breakdown of tattoo pigment within the hypodermis or dermal layer, except in the method of salabrasion.18 Based on the above information, theories suggest that by inducing the release of growth factors such as; Plateletderived Growth Factor (PGF), Transforming Growth Factor alpha and beta (TGF-and TGF-?), and Fibroblast Growth Factor (FGF), the normal process of wound healing is re-initiated, enabling any scars present to heal to an aesthetically acceptable point.16,17 Based on this theory of the acute inflammatory process, which leads to both initial phagocytosis (breaking down) of any foreign body present, as well as engulfing by macrophages, it is felt that micro needling could contribute to the breakdown of tattoo pigment within the hypodermal layer.19

Conclusion

As no biopsy was undertaken, there was a lack of histological evidence to confirm the presence of tattoo pigment within the lesion. There was, however, both historical and observational evidence determining its presence. The results of the treatment showed a significant improvement of the residual pigment and surrounding hypertrophic and hyper-pigmented scar with just five sessions of microneedling. This suggests that microneedling offers a new, effective and safe means for the treatment of leakage of tattoo ink into the dermal and hypodermal layers.3

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