The Non-Healing Tattoo


The Case: A 25-year-old male presented to the emergency department rapid care center complaining of an infection to his left lower extremity. He had a tattoo placed with red and green ink 2 weeks ago, and has noticed progressively worsening redness and pruritis developing, and a nonhealing wound with elements of the tattoo sloughing off. He denied fever, sore throat, nausea, vomiting, and shortness of breath, abdominal pain, hives and joint pain. The present discomfort is mild and somewhat pruritic. Scratching and pressure on site aggravate the area, and no relief was obtained with Keflex x 1 week.

The patient has not had similar symptoms in the past. There was no history of trauma prior to the placement of the tattoo.

The patient denies smoking, alcohol or drug abuse nor any past medical/surgical history or allergies.


On physical examination the patient was in moderate discomfort. His blood pressure was 151/51, pulse 90, respiratory rate 18, pulse oxygenation 98%, and temperature 97.2F. His pain scale was documented as 7/10.

The tattoo was a cartoon character located on his lateral left lower extremity wearing a hat and shirt in red dye ink, and other portions of the cartoon being in neon green ink. Erythema and mild edema were isolated to the borders of the tattoo and did not extend between the ink portions. The hat and shirt areas were open lesions, moist and tender with clear discharge. The areas with neon green ink was actively sloughing off and moist and tender. No fluctuance was noted.

What are your concerns as you examine this patient?



Dx: Hypersensitivity to Tattoo Ink


Although an acute inflammatory reaction commonly occurs due to the soft tissue injury from the injected pigments, these usually resolve after several weeks. This patient had a hypersensitivity reaction to tattoo ink. It has been reported in the literature that tattoo allergy typically develops as a reaction to the ink in the tattoo (Hansan & Voutsalath, 2009) and most frequently is a contact dermatitis or a photoallergic dermatitis. The pigment dyes used for tattooing are prepared from metal salts. Red tattoo pigments, especially those made from mercury sulfide (cinnabar) cause the most frequent allergic reactions whereas yellow tattoo pigment (cadmium sulfide) is responsible for most photoallergic reactions. Other pigments utilized to create blue (cobalt aluminate), green (chromium oxide, lead chromate, or phthalocyanine) and black tattoos (logwood, iron oxide, or carbon) are much less common. Black tattoo pigment has been rarely reported to cause an allergic reaction. Phototoxic reactions may also occur in red tattoos due to the addition of cadmium, which is added in small amounts to intensify the red tattoo pigment.


Paraphenylenediamine (PPD) is a common allergen found in tattoo ink, temporary tattoo inks, and henna tattoos (Hansan & Voutsalath, 2009). Thimerosal is a mercury based chemical also reported to cause allergic contact dermatitis reactions in tattoos, however, mercury derived inks have been removed from the market due to their adverse side affects (Breithaupt & Jacob, 2008).

Allergic reactions tend to worsen over time; each exposure to the offending agent will cause an even worse reaction (Cowley, 2008). It is not uncommon for a patient to report having had previous tattoos with no complications, then reporting redness, nonhealing, pruritis with a recent addition of tattoo ink (Cowley, 2008). One person reported a new tattoo causing previously described symptoms in a new tattoo, as well as a 4-year-old tattoo with colored ink (Wiki, 2011). This person was treated with silver sulphadiazine dressings for 2 weeks with the older tattoo remaining intact with color and the new tattoo losing all color (Wiki, 2011).

The literature recommends acute treatment with antibiotic ointment, hydrocortisone creams, anti-itch creams and cold compresses; some dermatologists would also prescribed some form of systemic steroid for treatment (Cowley, 2008). Laser therapy is also an option in removing the offending agent by fragmenting the ink particles to a size where the body’s immune system can remove them (Cowley, 2008). Vitamin E, aloe vera and Qeurcitin (flavonoid) are also beneficial in aiding the immune system in rejuvenation and healing of skin (Cowley, 2008).

The wound cleansed with soap and water, and xeroform dressing applied to wound. The patient was referred to the dermatology clinic for a wound follow up as well as laser removal of the tattoo.

  • encyclopedia (2011) Ink Allergy. Reported on Wikipedia. Retrieved on May 20, 2011 from
  • Breithaupt, A & Jacob, S. (2008) Thimerosal and the relevance of patch-test reactions in children. Dermatitis. Vol 19(5) pp275-7
  • Cowley, D. (2008) Recognizing allergies to tattoos. Reported on Helium: Allergies. Retrieved on May 20, 2011 from



Dr. Effron is the assistant professor of emergency medicine at Case Western Reserve University and attending physician in the department of emergency medicine at the MetroHealth Medical Center, in Cleveland, Ohio.


  1. Linda Pietrucha, RHIT, CCS, CCS-P on

    I am so happy to get this newsletter. I appreciate being on the website to have it offered to us.

  2. Cadmium sulfide can be used for many purposes, including materials for photo-resistors; semiconductors; pure, inorganic photoconductors; colorants for soaps, textiles, paper, plastics and rubber; x-ray fluorescent screens; body temperature detectors; rectifiers; transistors; photovoltaic cells; solar cells; and photoelectric radiation.

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