Nicolas Kluger

A medical-toxicological view of tattooing

Long perceived as a form of exotic self-expression in some social fringe groups, tattoos have left their maverick image behind and become mainstream, particularly for young people. Historically, tattoo-related health and safety regulations have focused on rules of hygiene and prevention of infections. Meanwhile, the increasing popularity of tattooing has led to the development of many new colours, allowing tattoos to be more spectacular than ever before. However, little is known about the toxicological risks of the ingredients used. For risk assessment, safe intradermal application of these pigments needs data for toxicity and biokinetics and increased knowledge about the removal of tattoos. Other concerns are the potential for phototoxicity, substance migration, and the possible metabolic conversion of tattoo ink ingredients into toxic substances. Similar considerations apply to cleavage products that are formed during laser-assisted tattoo removal. In this Review, we summarise the issues of concern, putting them into context, and provide perspectives for the assessment of the acute and chronic health effects associated with tattooing.

Black lymph nodes--and a colourful skin.

In March, 2001, a 38-year-old man presented with painful, sometimes tender, lumps in his armpits. The size of the lumps fl uctuated—sometimes, their diameter reached 20–25 mm, so it was painful for the patient to have his arms by his sides. The lumps had been present since the beginning of the year. The patient had no history of fever, weight loss, or night sweats. He had smoked cigarettes for 10 years, but otherwise had no notable medical history—except for hepatitis B, from which he had fully recovered. Examination revealed tender, enlarged (diameter 10–25 mm) lymph nodes in both armpits, especially the left armpit. The only other fi nding of note was that the patient had many tattoos, dating back 20 years, on his arms, chest, abdomen, and back. Blood tests, including serological tests for hepatitis B virus, HIV, Epstein-Barr virus, cytomegalovirus, and toxoplasmosis, showed nothing of note. CT of the chest showed large lymph nodes in the axillae, and sporadic bullous dystrophy. We excised three lymph nodes, for analysis. They were dark grey, indicating the possibility of melanoma. However, histopathological analysis showed reactive follicular hyperplasia and sinus histiocytosis, implying reactive lymphadenopathy rather than cancer. Many histiocytes contained black pigment. We diagnosed reactive lymphadenopathy caused by tattoo pigment. The lymph nodes regressed spontaneously. When last contacted, in January, 2008, the patient was well, and said that he had had only one further episode of lymph-node swelling in the intervening 7 years. Tattoo pigments are taken up by macrophages, that migrate through lymph vessels to lymph nodes—which can be distant from the tattoo. The resulting reactive lymphadenopathy is like that found in skin diseases. Lymph nodes can reach a diameter of 3 cm, which might ordinarily be held to indicate cancer; macrophages in lymph nodes can take up 18-fl uorodeoxyglucose, causing cancer to be suspected (wrongly) on PET scanning. Since tattooing is becoming more common in Europe and North America, we expect the incidence of tattoo-induced lymphadenopathy to increase. The onset of lymph adenopathy can be delayed, so doctors should not forget to ask, if appropriate, whether the patient has had a tattoo removed. However, lymphadenopathy caused by tattoos remains a diagnosis of exclusion.

Specifically requesting surgical tattoo removal: are deep personal motivations involved?

Backgroundu2002 Motivations for tattoo removal include employment reasons, stigmata, changes in lifestyles or partners, incompatibility with present attitudes and values and clothing problems. Most studies on the motivations for tattoo removal have focused on patients seeking laser therapy. We hypothesized that patients seeking surgical tattoo removal would present with different motivations.

Absence of some common organ-specific and non-organ-specific autoimmunity in autoimmune polyendocrinopathy candidiasis ectodermal dystrophy

Background Autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED) is a rare autosomal recessive disorder caused by mutations of the autoimmune regulator (AIRE) gene, whose loss of function leads to the escape of self-reactive T cells from the thymus and autoimmunity. APECED patients typically develop tissue-specific autoantibodies and anti-cytokine antibodies. Consequently, various endocrine and non-endocrine autoimmune disorders appear. However, only a certain number of autoimmune diseases develop, while some common autoimmune conditions have not been reported or are seen only anecdotally. Objective We investigated the clinical manifestations and occurrence of antinuclear antibodies (AN-Abs) and antibodies against extractable nuclear antigens, citrullinated peptide, and transglutaminase in 24 patients and against bullous pemphigoid antigen 180 and desmogleins 1 (Dsg1) and Dsg3 in 30 patients of a Finnish cohort of APECED patients. Results Despite the loss of central tolerance, the autoantibodies investigated were not overrepresented among the APECED patients. None of the patients had a history of autoimmune connective tissue disease, rheumatoid arthritis, celiac disease, or autoimmune cutaneous bullous disorders. Altogether, 25% (6/24) had low-titer (1:80) AN-Abs. Two patients had anti-BP180 antibodies and two others had anti-Dsg3 antibodies without any cutaneous or mucosal symptoms. No anti-citrullinated peptide and anti-transglutaminase reactivity was found. Conclusions The mechanisms that drives tolerance to tissue autoantigens is not fully understood as even APECED patients, who are genetically prone to develop autoantibodies, are tolerant against some common autoantigens. The hypothesis that some of the anti-cytokine antibodies commonly found in APECED patients may be protective should be investigated in larger series.

A Practical Guide About Tattooing in Patients with Chronic Skin Disorders and Other Medical Conditions

With tattoos becoming increasingly mainstream, dermatologists are more and more often consulted by patients who are considering getting an ornamental, cosmetic, or even a medical tattoo, and who subsequently ask for advice. This includes not only patients with chronic skin diseases such as psoriasis or atopic dermatitis but also patients with other medical conditions. This review first explores the reasons why patients may want to get a tattoo and aims to offer some key information to dermatologists on what they should know about tattooing and the main risks associated with this procedure. Second, the risks and recommendations of tattooing in patients with specific skin diseases are described more in detail, and the relative and strict contraindications discussed, including the necessity to discontinue certain treatments that could influence the outcome of the procedure and the final result. Our aim was to provide dermatologists with the current knowledge they need to help their patients make adequate and informed choices on skin art, focusing specifically on considerations in patients with chronic skin conditions. Finally, other aspects regarding some general systemic conditions and concomitant diseases that the patient could present are also addressed. In particular, the risks of tattooing in patients with diabetes, coagulation disorders, heart conditions, immunosuppressive treatments, and pregnancy are discussed.

Comorbidities of bullous pemphigoid in a Finnish cohort

BackgroundThe incidence of bullous pemphigoid (BP) is increasing in Finland.ObjectivesTo investigate the clinical presentation, comorbidities, and medications in a cohort of Finnish patients with confirmed BP managed in a university hospital setting.Materials & MethodsAn observational retrospective study of all consecutive patients diagnosed with BP in 2012-2013 at the Department of dermatology, HUCH. The prevalence of the most common comorbidities was compared to that in a sample population aged over 30 years.ResultsSeventy patients were included (mean age: 77 years at diagnosis). The most common comorbidities were hypertension (44%), type 2 diabetes (34%), and ischaemic heart disease (26%). Almost half of the cohort had a neurological condition (46%). A statistically significant association was identified between BP and a past history of malignancies (17%; p<0.001), type 2 diabetes (24%; p<0.001), and chronic obstructive lung disorder (COPD) (10%; p=0.004), compared to an age-matched control group. The most common standard drugs were statins, beta-blockers, and diuretics. In total, 83% of the patients with type 2 diabetes took anti-diabetic treatments, mainly metformin (80%) and gliptins (55%).ConclusionsSignificant associations were identified between BP and COPD, type 2 diabetes, and a past history of malignancy, compared to the general population. In this study, the specific role of some medications, such as gliptins, may account for the onset of BP in diabetic type 2 patients.

Tattooing and immunodepression: Caution is warranted also in organ transplant patients

I read with great interest the report by Trinh and Angarone1 on a case of Purpureocillium lilacinum infection after decorative tattooing in a patient with a kidney transplant. With the increasing popularity of tattooing, patients with immunocompromised conditions or those treated by immunosuppressive drugs may desire to get tattooed. Although professional tattooists have improved in the field of hygiene and asepsis, there is no such thing as zero risk. Cutaneous pyogenic infection, rapidly growing mycobacteria, as well as exceptional cases of fungal or parasitic infections have been reported in immunocompetent hosts.2 To date, very few cases of complications related to tattooing have been reported in the context of immunosuppression.3 A lethal case of septic infection after tattooing was reported in a young patient with relapsing acute myeloid leukemia.4 In the case reported by Trinh and Angarone,1 inoculation may have occurred during tattooing or at home, during the healing phase, owing to lack of sufficient aftercare. However, the restriction of the lesions on the gray shadings in the Figure1 could indicate the possible use of unsterile/ tap water by the tattooist, as has been observed leading to infection with environmental mycobacteria.5 It is not possible to draw a conclusion if the whole situation or a specific factor precipitated the infection by P. lilacinum (renal transplant, rituximab, bortezomib, etc.). Patients do not always perceive the possible infectious risks related to their condition. They are also reluctant to discuss their desire to get a tattoo openly with the treating physician because of the fear of a judgmental approach, and they may consider that the health care specialist is not knowledgeable about tattooing. We recently published several suggestions on dealing with immunocompromised hosts who may conceal wishes for bodyart (including tattooing).3 These suggestions can apply to treatment of any organtransplanted patient. It is of outmost importance to discuss openly the topic with young patients early on. The physician should enquire about any potential wish for a tattoo. Patients who are already tattooed are more likely to get a new one. A nonjudgmental approach is mandatory to allow a better adherence to recommendations. Reasons for contraindications should be explained to the patient, stressing that these are/may be only temporary and in relation to the risk of severe infections. Tattooing can always be reconsidered, when the treatment is at an acceptable maintenance level. In case the physician would give a green light for getting a tattoo, the patient should choose a professional tattooist who respects the rules of asepsis and hygiene in his/her parlor and patients should avoid home tattooing. The tattooist should be made aware of the patient’s medical situation, so that he can take the maximum precautions to avoid potential inoculation, such as using new tattoo ink bottles for the patient, performing shorter session, paying attention to any unusual local symptom before a new session, and having the patient consult medical care immediately in case of such symptoms. We hope that these suggestions may help physicians involved with patients with organ transplant who have a wish for tattoos, and prevent in the future such unwarranted complications as reported in Transplant Infectious Disease.

Koebner's sheep in Wolf's clothing: does the isotopic response exist as a distinct phenomenon?

Until 1995, a case of psoriasis developing within the dermatome of a healed herpes zoster was taken as a Koebner phenomenon. In this year, however, the term ‘isotopic response’ was introduced by Wolf et al. to describe ‘the occurrence of a new skin disorder at the site of another, unrelated and already healed skin disease’, thus appearing ‘on apparently unaffected and healthy skin’. Initially, the term was mainly related to herpes zoster, but today the name ‘Wolfs isotopic response’ is used to include a plethora of other triggering factors such as healed cutaneous leishmaniasis, tinea or varicella. For obvious reasons, such triggering factors cannot be taken as examples of ‘unaffected and healthy skin’. Notably, the authors themselves have categorized the dermatome of a healed herpes zoster as a ‘vulnerable area’. In a recent commentary, Wolf et al. have expanded the definition of healed skin diseases triggering an ‘isotopic response’. They now included ‘scars, pigment changes, color changes or various other minimal changes by the first disease’. Hence, there is no clear‐cut criterion to distinguish the isotopic response from a Koebner reaction. Wolf et al. even argue that, if the triggered disorder precedes the appearance of generalized skin lesions, then it is not a Koebner reaction but ‘Wolfs isotopic response’. In our view, such definition is unacceptable. All reactions of this kind represent examples of a Koebner phenomenon. Accordingly, the ‘isotopic response’ should today be taken as a historical error.

Dermatoporosis and vitamin C deficiency

I read with great interest both the article by Humbert etxa0al reporting the efficacy of a 5% vitamin C cream in the treatment of Bateman purpura1 and the commentary by Kaya et al2 about dermatoporosis. Several years ago, we reported the case of an 85 year-old woman who presented with extensive blistering purpura and spontaneous hematomas of the lower limbs in relation to dermatoporosis3 (Figurexa01). The patient did not take any antiplatelet or anticoagulation therapy, nor corticosteroids. However, vitamin C blood level were found to below normal ranges (ascorbemia < 5 mg/l but > 2 mg/l). Our patient did not present any other signs of scurvv. With rest, our patient was discharged home with oral vitamin C. This article is protected by copyright. All rights reserved.

Phénomènes de Köbner, Renbök, Wolf et Cie… est-il temps de simplifier ?

Since the end of the 19th century, dermatologists have observed that skin conditions may respond (or not) to a wide variety of skin injuries or even to other existing skin conditions. Attempts were made to name and classify such phenomena: Köbner phenomenon, Wolfs isotopic response, Renbök phenomenon, etc. However, over time, further subtleties and nuances came to be grafted onto the initial descriptions, while comparable phenomena were described using different terms, all of which resulted in considerable confusion in the literature. Herein we review the history, semantics and nosology of these different phenomena. We also propose the use of a simpler, more homogenous and universal nomenclature that distinguishes between affinity and sparing phenomena, whether isomorphic or isotopic and which is based on the lesions involved (trauma, vaccination, radiotherapy, neurologic defect, herpes, genetic mosaicism and so on).