Terrence Keaney，醫學博士，FAAD； Daniel P. Friedmann，醫學博士，FAAD； Vineet Mishra，醫學博士，FAAD/ 2024 年 9 月 26 日/ Medscape醫療景觀
圖片由 Bassi A、Campolmi P、Cannarozzo G 等人提供。生物醫學研究中心。 2014；2014：354608。 PMID：25147796。［開放存取］。
上圖顯示（左）紋身紅色區域的假性淋巴瘤反應，以及（右）使用 Q 開關摻釔鋁石榴石晶體脈衝雷射Neodymium-doped Yttrium Aluminum Garnet Pulse Laser (Nd:YAG) 進行四次治療後病變消退的情況。
儘管與紋身和去除紋身相關的併發症通常是輕微的且具有自限性，但兩者都可能發生嚴重的不良事件。將外來色素引入皮膚可能會導致色素的發炎反應、傳染病的傳播以及繼發於創傷的紋身內皮膚病的局部化。此外，紋身去除通常使用發射奈秒或皮秒 (註) 範圍超短脈衝的固態雷射進行，也存在許多潛在的併發症。這些包括燒傷、水泡、感染、不規則色素沉著，以及罕見的疤痕。
註：什麼是皮秒 (Picosecond)？ 「皮秒」(英文名：Picosecond，縮寫為ps)指的是10-12 秒（ 萬億分之1 秒），是一個時間單位。
圖片來自科學來源。
這張人體皮膚橫截面的光學顯微照片顯示了一層紋身墨水（在 35 毫米感測器上放大 200 倍）。
當用針將永久性墨水插入真皮（皮膚的下層）時，就會形成紋身。外源性紋身顏料顆粒的直徑為 2-400 nm，可位於細胞外，或被真皮纖維母細胞、巨噬細胞或肥大細胞攝取後，位於細胞內。
圖片由 Chakir K、Hassam B. Pan Afr Med J. 2013；15:148 提供。 PMID：24396554。
這張圖片顯示了對指甲花 (henna) 紋身的大皰（或起泡）過敏反應。
對紋身顏料的過敏是一種潛在的不良事件，可能在數天到數月內以多種方式表現出來，包括接觸性皮膚炎或光過敏性皮膚炎。
圖片由 Bassi A、Campolmi P、Cannarozzo G 等人提供。生物醫學研究中心。 2014；2014：354608。 PMID：25147796。 ［開放存取］。
顯示的是（a）紅色紋身上的假性上皮瘤增生反應和（b）真皮中的發炎（箭頭）。
當免疫系統因先前接觸紋身顏料而變得過敏時，就會發生對紋身的過敏性超敏反應。紅色顏料是引起此類反應的最常見原因，但任何紋身顏料都可能引發這些反應。例如，過敏反應可能是對多種金屬鹽的反應，這些金屬鹽可用於產生不同的顏色，例如鎘（黃色）、錳（紫色）、鈷（藍色）和鉻（綠色）。
圖片來自科學來源。
這張特寫照片顯示了一位 39 歲女性手腕上的皮疹，顯示紋身部位出現了苔蘚樣皮膚炎。
過敏反應可以用局部和病灶內皮質類固醇或抗組織胺治療，以減輕發炎和搔癢。可以考慮手術切除來治療發炎的紋身。雷射治療可能在多次治療後得到緩解；然而，考慮到可能誘發全身性過敏反應，雷射治療後應在診間對患者進行至少 30 分鐘的監測。
圖片由 Lawrence Charles Parish 醫學博士（賓夕法尼亞州費城教區皮膚科）提供。
這些圖像顯示對紅色紋身顏料過敏引起的接觸性皮膚炎。硫化汞（硃砂）是這些情況下最有可能的罪魁禍首。當使用硫化汞進行色素沉著時，對紅色紋身的過敏反應更為常見，但其他品種的顏料也可能引起此類過敏反應。
斑貼測試對於氯化汞可能呈現陽性，但此測試對於硃砂並不可靠。由於與含汞紅色紋身顏料相關的問題，已經開發出替代紅色染料；然而，紅色紋身反應，如肉芽腫性和結節性紋身皮膚反應，不斷有報導。
圖片由 Ruiz-Villaverde R、Sánchez-Cano D. Pan Afr Med J. 提供，2013 年 10 月 11 日；16:49。 PMID：24648862。
這張圖片顯示了一名 23 歲患者的腹部，他的刺青上出現了珍珠狀丘疹。該患者被診斷出患有傳染性軟疣，該疾病可能是透過不乾淨的儀器或受污染的墨水傳播的。
儘管目前紋身的衛生和感染控制標準已經使感染變得罕見，但由於表皮屏障的破壞，細菌仍然可能經皮引入。據報導，刺青還會傳播結核病、非典型分枝桿菌、梅毒、痲瘋、肝炎和人類免疫缺陷病毒 (HIV)。
圖片來自 Science Photo Library（左上、右下）和 Alamy（右上、左下）。
調Q奈秒和皮秒雷射是去除紋身主流的方法，允許對外源性色素顆粒造成熱損傷，同時對周圍皮膚的傷害最小。綠色紋身顏料在 694 或 755 nm 波長下去除效果最佳，紅色紋身顏料在 532 nm 波長下去除效果最佳，藍色和黑色顏料在 694、755 或 1064 nm 波長下去除效果最佳。黃色和橙色紋身顏料較難去除，但通常可以使用 532 奈米波長進行有效處理。
圖片由醫學博士、哲學博士 Douglas C. Wu 提供； Ana M. Liolios，醫學博士；和 Mitchel P. Goldman，醫學博士（美容雷射皮膚科，聖地亞哥，加利福尼亞州）。
起泡是與雷射紋身治療相關的暫時性不良事件。這種情況在前幾次治療中更為常見，是由於發炎滲出物快速累積繼發的表皮下大皰形成所致。白人男性（左）外側手臂上的這個彩色紋身是用 Q 開關皮秒翠綠寶石（755 nm）雷射進行治療的。第一次治療後出現大面積水泡，持續約 5 天（中）。起泡通常會在雷射治療後幾天內消退，不會留下疤痕或其他後遺症（右）。紋身雷射治療後立即使用燒蝕分次換膚可顯著降低大皰形成的發生率。
圖片由 Daniel P. Friedmann 醫學博士提供。
Q開關雷射治療後表淺皮膚感染並不常見。在第一次 Q 開關皮秒紫翠玉（755 nm 和 532 nm）雷射治療她的彩色足部紋身後兩週，該患者出現瀰漫性淺表紅斑；結痂；和滲出，伴隨偶爾的搔癢。她一直在使用醫生推薦的溫和治療藥膏，但徵兆和症狀逐漸惡化。傷口培養顯示存在耐甲氧西林金黃色葡萄球菌（methicillin-resistant S aureus , MRSA），提示膿皰瘡的診斷。多喜四環黴素 (Doxycycline )100 毫克，每天口服兩次，持續 10 天，病情完全緩解。
圖片由 Daniel P. Friedmann 醫學博士提供。
使用相同的 Q 開關皮秒翠綠寶石（755 奈米和 532 奈米）雷射對先前患者進行再治療，僅導致紅色紋身區域出現紅斑、凸起、搔癢斑塊。研究結果與雷射治療引起的對紅色紋身顏料的過敏性接觸超敏反應一致。患者否認紋身後有任何類似的徵兆和症狀。有趣的是，同腳腳踝內側的紅色刺青未經治療，同時出現紅斑和搔癢。
圖片來自科學來源。
這張圖片顯示了一名成年女性在雷射治療紋身後手臂上出現的肥厚性疤痕和色素沉著。
調Q奈秒和皮秒雷射很少會造成疤痕。然而，當這些設備在不適當的高通量下使用時，多次處理後可能會出現顯著的質地和色素變化。
圖片由 Daniel P. Friedmann 醫學博士提供。
一名62歲的女士要求矯正眉毛紋身。紋身的尾部採用 Q 開關皮秒翠綠寶石（755 nm）雷射進行處理。治療後立即觀察到治療區域變黑。這很可能是由於雷射介導的氧化鐵（Fe2O3，鐵鏽色）還原為氧化亞鐵（FeO，黑色）。每月對同一區域重複進行雷射治療可以解決問題。
圖片來自科學圖片庫。
可以進行手術切除和植皮來去除紋身，特別是對紋身過敏的患者。在雷射去除紋身成為照護標準之前，這些手術更為常見。這張特寫圖片顯示了一名男子治療過程中手臂上的植皮部位。
Tattoo Skin Reactions: Allergies and Infections
Terrence Keaney, MD, FAAD; Daniel P. Friedmann, MD, FAAD; Vineet Mishra, MD, FAAD
| September 26, 2024 | Medscape
Image courtesy of Bassi A, Campolmi P, Cannarozzo G, et al. Biomed Res Int. 2014;2014:354608. PMID: 25147796. PMCID: PMC4132403. [Open access.]
The above image shows (left) a pseudolymphomatous reaction in the red-pigmented region of a tattoo and (right) lesion resolution following four treatments with a Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser.
Although the complications associated with tattooing and tattoo removal are often mild and self-limited, significant adverse events are possible with both. The introduction of foreign pigments into the skin can result in inflammatory reactions to the pigments, the transmission of infectious diseases, and the localization of skin disease within tattoos secondary to trauma. Moreover, the removal of tattoos, typically performed with solid-state lasers that emit ultrashort pulses in the nanosecond or picosecond range, is also not without its host of potential complications. These include burns, blisters, infections, irregular pigmentation, and, rarely, scarring.[1]
Image from Science Source.
This light micrograph of a cross section of human skin shows a layer of tattoo ink (200× magnification on a 35-mm sensor).
A tattoo is made when permanent ink is inserted into the dermis (lower layer of the skin) with a needle. Exogenous tattoo pigment granules measure 2-400 nm in diameter and can be located extracellularly or, following ingestion by dermal fibroblasts, macrophages, or mast cells, intracellularly.[4]
Image courtesy of Chakir K, Hassam B. Pan Afr Med J. 2013;15:148. PMID: 24396554. [Open access.]
This image shows a bullous (or blistering) allergic reaction to a henna tattoo.
An allergic hypersensitivity to tattoo pigments is a potential adverse event that may manifest itself over days to months in several ways, including contact dermatitis or photoallergic dermatitis.
Image courtesy of Bassi A, Campolmi P, Cannarozzo G, et al. Biomed Res Int. 2014;2014:354608. PMID: 25147796. PMCID: PMC4132403. [Open access.]
Shown are (a) a pseudoepitheliomatous hyperplastic reaction on a red tattoo and (b) inflammation in the dermis (arrow).
Allergic hypersensitivity reactions to tattoos occur when the immune system is hypersensitized to the tattoo pigment due to prior exposure. Red pigments are the most common cause of such reactions, but any tattoo pigment may elicit them. For example, allergic reactions can be a response to a variety of metallic salts that may be employed to produce different colorations, such as cadmium (yellow), manganese (purple), cobalt (blue), and chromium (green).
Image from Science Source.
This close-up image of a rash on the wrist of a 39-year-old woman shows a lichenoid dermatitis at the site of a tattoo.
Allergic reactions can be treated with topical and intralesional corticosteroids or antihistamines to reduce inflammation and itching. Surgical excision can be considered for the treatment of inflamed tattoos. Laser therapy may lead to resolution after multiple treatments; however, patients should be monitored in-office for at least 30 minutes following laser treatment, given the potential for induction of a systemic allergic reaction.
Images courtesy of Lawrence Charles Parish, MD (Parish Dermatology, Philadelphia, PA).
These images show contact dermatitis caused by allergic hypersensitivity to red tattoo pigments.[5] Mercury sulfide (cinnabar) is the most likely culprit in these cases. Allergic reactions to red tattoos are more common when mercury sulfide is used for pigmentation, but other varieties of pigments can also cause such hypersensitivity reactions.
Patch testing may be positive for mercury chloride, but this test is not reliable for cinnabar. Alternative red dyes have been developed because of the problems associated with mercury-containing red tattoo pigments; however, red tattoo reactions, such as granulomatous and nodular tattoo skin reactions, continue to be reported.
Image courtesy of Ruiz-Villaverde R, Sánchez-Cano D. Pan Afr Med J. 2013 Oct 11;16:49. PMID: 24648862. [Open access.]
This image shows the abdomen of a 23-year-old patient who presented with pearled papules over a tattoo. The patient was diagnosed with molluscum contagiosum, which may have been transmitted through unclean instruments or contaminated ink.
Although current standards for hygiene and infection control in tattooing have made infections unusual, bacteria may still be introduced percutaneously due to breach of the epidermal barrier. Transmission of tuberculosis, atypical mycobacteria, syphilis, leprosy, hepatitis, and human immunodeficiency virus (HIV) from tattooing has also been reported.[7]
Images from Science Photo Library (top left, bottom right) and Alamy (top right, bottom left).
Q-switched nanosecond and picosecond lasers are the mainstays of tattoo removal, allowing for thermal damage to exogenous pigment particles with minimal injury to the surrounding skin.[7,8] Selection of an appropriate laser wavelength is based entirely on the color(s) of the tattoo pigment(s) being targeted, with the wavelength chosen by means of “complementary matching.” Green tattoo pigment is most effectively removed by a wavelength of 694 or 755 nm, red tattoo pigment is best removed with a 532-nm wavelength, and blue and black pigments are removed with a 694-, 755-, or 1064-nm wavelength.[9] Yellow and orange tattoo pigments are more difficult to remove but can often be treated effectively with a 532-nm wavelength.
Images courtesy of Douglas C. Wu, MD, PhD; Ana M. Liolios, MD; and Mitchel P. Goldman, MD (Cosmetic Laser Dermatology, San Diego, CA).
Blistering is a transient adverse event associated with laser tattoo treatment. It is more common with the first few treatment sessions and is due to subepidermal bullae formation secondary to rapid accumulation of inflammatory exudate. This multicolored tattoo on the lateral arm of a Caucasian male (left) was treated with a Q-switched picosecond alexandrite (755-nm) laser. Extensive blistering developed after the first treatment session and lasted approximately 5 days (middle). Blistering typically resolves within several days of laser therapy without scarring or other sequelae (right). The use of ablative fractionated resurfacing immediately following tattoo laser treatment dramatically decreases the incidence of bullae formation.[11]
Image courtesy of Daniel P. Friedmann, MD.
Superficial skin infections are uncommon following Q-switched laser therapy. Two weeks following the first Q-switched picosecond alexandrite (755-nm and 532-nm) laser treatment of her multicolored foot tattoo, this patient returned with diffuse, superficial erythema; crusting; and oozing, associated with occasional pruritus. She had been applying a physician-recommended, bland healing ointment, with progressive worsening of signs and symptoms. Wound culture revealed the presence of methicillin-resistant S aureus (MRSA), suggesting a diagnosis of impetigo. Doxycycline 100 mg taken orally twice daily for 10 days led to complete resolution.
Image courtesy of Daniel P. Friedmann, MD.
Retreatment of the prior patient with the same Q-switched picosecond alexandrite (755-nm and 532-nm) laser led to erythematous, raised, pruritic plaques localized to the red tattoo areas only. Findings were consistent with an allergic contact hypersensitivity to red tattoo pigment, elicited by laser treatment. The patient denied having had any similar signs and symptoms following tattooing. Interestingly, an untreated red tattoo on the medial ankle of the same foot developed erythema and pruritus concurrently.
Image from Science Source.
This image shows hypertrophic scarring and dyspigmentation on the arm of an adult female following laser treatment of a tattoo.
Q-switched nanosecond and picosecond lasers rarely result in scarring. However, there can be significant textural and pigmentary changes after multiple treatments when these devices are used at inappropriately high fluences.
Image courtesy of Daniel P. Friedmann, MD.
A 62-year-old woman requested correction of her eyebrow tattoo. The tail of the tattoo was treated with a Q-switched picosecond alexandrite (755-nm) laser. Darkening of treated areas was noticed immediately posttreatment. This was most likely due to the laser-mediated reduction of ferric oxide (Fe2O3, rust colored) to ferrous oxide (FeO, black colored). Repeat monthly laser treatments of the same area led to resolution of the problem.
Image from Science Photo Library.
Surgical excision and skin grafting can be performed to remove tattoos, particularly in patients with allergic hypersensitivity to their tattoos. These procedures were more commonly performed before laser tattoo removal became the standard of care. This close-up image shows a skin graft site on a man’s arm midway through his treatment.