British Journal of Dermatology 2003; 149: 94–98.

Dermatological Surgery and Lasers

Red ink tattoo reactions: successful treatment
with the Q-switched 532 nm Nd:YAG laser
F.C.ANTONY AND C.C.HARLAND
Department of Dermatology, St Helier Hospital, Carshalton, Surrey, SM5 1AA, U.K.

Accepted for publication 17 November 2002

Summary Background In the South-west Thames region there were an unprecedented number of lichenoid
tattoo reactions to red ink in patients who had visited a local tattoo parlour. The red ink was found
to contain mercuric sulphide, a compound known to cause allergic reactions. Topical DermovateÒ
(clobetasol propionate 0Æ05%, GlaxoWellcome) ointment alone had little impact.
Objectives To investigate whether the Q-switched 532 nm Nd:YAG laser could produce permanent
flattening of the reaction.
Methods This was an open nonrandomized clinical trial. Biopsies were taken from the lichenoid
areas within the tattoos. Subjects were patch tested to 1% ammoniated mercury in petrolatum prior
to treatment with the Q-switched 532 nm Nd:YAG laser. Laser treatments were delivered at
6-weekly intervals by a single operator. Patients also applied topical DermovateÒ between
treatments. Therapy was discontinued when the lesions flattened. Clinical photographs were
assessed at baseline and prior to each laser treatment.
Results Seven patients with Fitzpatrick skin types I–III were enrolled in the study (four females,
three males, mean age 39 years). All patients completed the trial. Patch testing to mercury was
universally negative at 48 and 96 h. Substantial flattening and depigmentation of the red ink
within the tattoos was noted after six laser treatments. No adverse effects were recorded.
Conclusions The Q-switched 532 nm Nd:YAG laser in combination with topical DermovateÒ
ointment is a safe and effective method of treating red ink tattoo reactions.
Key words: 532 nm Nd:YAG laser, red ink tattoo reaction

Tattoos occasionally have unfortunate consequences.
The introduction of a foreign substance into the skin
can promote a toxic or an immunological response.
This reaction is more common with red ink, which may
contain mercury-related compounds. We had an influx
of patients with red ink tattoo reactions to the
Department of Dermatology, St Helier Hospital over
the course of 6 months. Most of these patients had
visited the same tattoo parlour. The batch of red ink
was later found to contain cinnabar (mercuric sul-
phide). Laser intervention for red tattoo reactions has
been hitherto considered to be unsafe because of the
theoretical risk of anaphylaxis.1
Correspondence: Dr F.C.Antony.
E-mail: fiantony@hotmail.com
The reactions were unresponsive to topical
DermovateÒ ointment (clobetasol propionate 0Æ05%,
GlaxoWellcome Stevenage, UK) under occlusion. There
have been two previous cases reporting the success of
the Q-switched 532 nm Nd:YAG laser in a red tattoo
reaction so we wished to establish the benefit of this
laser in our group of patients.2,3
Methods
Patients
All patients were referred by their general practitioners
and presented similarly with pruritus, swelling and
discomfort in the red portion of their tattoos. The
symptoms had all developed 2 days after having the
tattoo performed and were unresponsive to topical

94 Ó 2003 British Association of Dermatologists

 RED INK TATTOO REACTIONS 95

DermovateÒ ointment under occlusion for 2 months.
Patients had Fitzpatrick skin types I–III. Examination
revealed erythema, swelling and induration of the red
areas of the tattoos; other colours were unaffected.
There was no evidence of peripheral lymphadenopathy.
Biopsies were taken for histology from the indurated
areas.
Chest X-ray and patch tests
A chest X-ray was performed to rule out bilateral
inguinal lymphadenopathy suggestive of concomitant
sarcoidosis. Patch testing to 1% ammoniated mercury
in petrolatum only was performed at 48 and 96 h
using standardized techniques. A full supply of all the
pigments within the red dye was unavailable.
Laser therapy
We employed the Q-switched 532 nm Nd:YAG laser
(Medlite, Continuum Biomedical, Santa Clara, CA,
U.S.A.), 2–3 mm beam diameter, pulse width
) 20 ns, at increasing fluences of 1Æ4–6Æ4 J cm)2
following an initial test area. Laser treatments were
carried out at 6-weekly intervals by the same
operator. Patients were instructed to use topical
DermovateÒ ointment in between visits. Treatment
was confined to the affected areas, aiming to produce
a temporary whitening of the epidermis. Laser
therapy was discontinued after flattening of the
lesion occurred. Examination for lymphadenopathy
was done at each visit. Clinical photographs were
assessed at baseline and prior to each laser interven-
tion.
Consent
Written, informed consent was obtained from all the
patients warning of depigmentation, scarring, the rare
development of black pigmentation within the red area
and of the remote possibility of a type I hypersensitivity
reaction.
Results
Seven patients were enrolled in the study (four females,
three males, mean age 39 years). All patients comple-
ted the study.
Table 1 illustrates the demographic details of the
patients, histology and laser treatments required. The
chest X-ray in all the patients was normal. Patch testing
to mercury was universally negative at 48 and 96 h.
On average, substantial flattening and depigmenta-
tion of the red tattoo reactions was noted after six laser
treatments (Fig. 1a,b). However, hypertrophic, licheni-
fied reactions on the lower leg were much slower to
respond, requiring eight laser treatments (Fig. 2a,b).
Safety and tolerability
Initial erythema after the laser treatment lasted for 1 day
and was followed by superficial erosion and crust forma-
tion of the area, which took approximately 1 week to heal
with the application of aloe vera gel. No other adverse
events were recorded. In particular, no lymphadenopathy
was noted. Patients reported relief of pruritus on comple-
tion of the treatment. One patient required topical EmlaÒ
(AstraZeneca, Luton, UK) cream (lignocaine 25 mg g)1,
prilocaine 25 mg g)1) prior to laser treatment.
Histology
The most common histological pattern noted was a
lichenoid reaction. Figure 3 illustrates the histological
reaction patterns seen.
Follow-up
At 6 months all affected areas remained flat. One
patient with a hypertrophic lichenoid reaction on the

Table 1. Demographic details of the patients, histology and laser treatments required
Age Tattoo Mean Mean no. of No. of laser
Sex (years) location Histology fluence (J cm)2) shots per laser treatment treatments to flatten the lesion
M 36 Leg Nodular inflammatory infiltrate 5Æ3 1018 7
M 50 Leg Lichenoid inflammatory infiltrate 5Æ3 1763 8
F 31 Back Lichenoid inflammatory infiltrate 5Æ4 2103 6
M 45 Arm Lichenoid inflammatory infiltrate 4Æ2 1846 7
F 39 Back Granulomatous inflammatory infiltrate 3Æ3 1491 7
M 51 Arm Lichenoid inflammatory infiltrate 4Æ6 1634 6
F 35 Back Nodular inflammatory infiltrate 5Æ2 1966 6

Ó 2003 British Association of Dermatologists, British Journal of Dermatology, 149, 94–98

96 F.C.ANTONY AND C.C.HARLAND
Figure 1. (a) Red tattoo reaction on the back before treatment. (b)
Red tattoo reaction on the back after six laser treatments showing
depigmentation and flattening.
lower leg had residual erythema in the area treated but
the remaining pigment was insufficient to excite a
recrudescence of the lichenoid reaction. Pruritus was
eliminated in all cases.
Discussion
Allergic reactions can occur to any tattoo pigment
but lichenoid reactions to red tattoo dye are the most
common.4 In the 1960s patch testing revealed
sensitivity to mercury and this compound was
replaced by alternative red dyes such as cadmium
red, sienna and organic substances such as sandal-
wood and brazilwood.5 However, despite the availab-
ility of these mercury-free alternatives, reactions to
red tattoo dye are still occurring as evidenced by our
cluster of cases. The problem lies in the lack of
Ó 2003 British Association of Dermatologists, British Journal of Dermatology, 149, 94–98
Figure 2. (a) Red tattoo reaction on the lower leg before treatment.
(b) Red tattoo reaction after eight laser treatments.
legislation governing the production of tattoo dyes
and thus it is often not known which substances are
used to produce them.6
Of note, all our patients were negative on patch
testing to mercury suggesting that other pigments
within the red dye may evoke the lichenoid reaction.
However, negative patch testing does not rule out
mercury as a cause because the hypersensitivity
initially created by the tattoo was provoked by intra-
cutaneous rather than epicutaneous challenge.
Various histological tattoo reaction patterns are
recognized. The chronic inflammatory cell infiltrate
may be nodular with a well-defined Grenz zone,7 liche-
noid with attenuation of the basal layer of the epider-
mis8 or granulomatous.9 A pseudolymphomatous

Figure 3. (a) A nodular inflammatory infiltrate with extracellular
pigment. (b) A lichenoid inflammatory infiltrate with extracellular
pigment. (c) A granulomatous inflammatory infiltrate with extracel-
lular pigment.
Ó 2003 British Association of Dermatologists, British Journal of Dermatology, 149, 94–98
RED INK TATTOO REACTIONS 97
pattern has also been reported where the infiltrate is so
dense that it may be indistinguishable from lymphoma
and immunohistochemistry may be necessary to con-
firm the diagnosis.10 It is always advisable to request a
chest X-ray and biopsy of a patient with a red tattoo
reaction as sarcoidosis may present as a granuloma-
tous reaction confined to a red tattoo.11
Three types of laser are currently used for tattoo
removal: the Q-switched ruby laser (694 nm), the
Q-switched Nd:YAG laser (532 nm, 1064 nm) and
the Q-switched alexandrite laser (755 nm).12 The
Q-switched ruby and alexandrite lasers are useful for
removing black, blue and green pigments. The
Q-switched 532 nm Nd:YAG laser can be used to
remove red pigments and the 1064 nm Nd:YAG laser is
used for removal of black and blue pigments. The
carbon dioxide laser has also been reported to be
beneficial for red ink tattoo removal. However, this
laser may also be associated with a significant degree of
scarring and local anaesthesia prior to laser therapy is
required.13 Other treatment options include surgical
excision, dermabrasion and intralesional triamcino-
lone. Our patients were keen to preserve the rest of
their tattoo so we used the Nd:YAG laser to produce
depigmentation and flattening of the reaction without
producing scarring.
No adverse type I hypersensitivity events were
recorded at any stage of the treatment period. However,
there has been widespread concern of anaphylactoid
reactions following a report by Ashinoff et al. who
described two cases of a generalized urticarial rash
7 days after using the Q-switched ruby laser for the
treatment of red tattoo reactions.1 They hypothesized
that the laser targeted the intracellular tattoo pigment
causing it to fragment and become extracellular. This
extracellular pigment was recognized by the patient’s
immune system as foreign and then initiated a local
and a generalized allergic reaction. In our experience of
over 500 episodes of treatment with the Nd:YAG laser
for tattoo removal no such reactions have occurred.
One possibility is that the Nd:YAG laser causes
fragmentation of the pigment which is then eliminated
in a transepidermal fashion. In addition there has been
a report of a tattoo producing localized lymphadenop-
athy.14 The lymph node in that case was found to
contain pigment material characteristic of a tattoo. All
our patients were examined for lymphadenopathy prior
to each laser treatment and no evidence of reactive
lymphadenopathy was found.
In conclusion, we have reported the safe and effective
use of the Q-switched 532 nm Nd:YAG laser in
98 F.C.ANTONY AND C.C.HARLAND
combination with topical DermovateÒ in treating red
tattoo reactions. However, further legislation is re-
quired to govern the use of pigments in dyes to prevent
a resurgence of these red tattoo reactions and we would
suggest that classic dyes such as cinnabar are com-
pletely replaced by synthetic dyes.
References
1 Ashinoff R, Levine VJ, Soter NA. Allergic reactions to tattoo
pigment after laser treatment. Dermatol Surg 1995; 21: 291–4.
2 Hindson C, Foulds I, Cotterill J. Laser therapy of lichenoid red
tattoo reaction. Br J Dermatol 1995; 133: 665–6.
3 Dave R, Mahaffey P. Successful treatment of an allergic reaction
in a red tattoo with the Nd:YAG laser. Br J Plast Surg 2002; 55:
456.
4 Taaffe A, Knight A, Marks R. Lichenoid tattoo hypersensitivity.
Br Med J 1978; i: 616–18.
5 Sowden JM, Byrne JPH, Smith AG et al. Red tattoo reactions:
X-ray microanalysis and patch-test studies. Br J Dermatol 1991;
124: 576–80.
Ó 2003 British Association of Dermatologists, British Journal of Dermatology, 149, 94–98
6 Lehmann G, Pierchalla P. Tattooing dyes. Derma Beruf Umwelt
1988; 36: 152–6.
7 Slater DN, Durrant TE. Tattoos: light and transmission electron
microscopy studies with X-ray microanalysis. Clin Exp Dermatol
1984; 9: 167–73.
8 Clarke J, Black MM. Lichenoid tattoo reactions. Br J Dermatol
1979; 100: 451–4.
9 Goldstein AP. Histological reactions in tattoos. J Dermatol Surg
Oncol 1979; 5: 896–900.
10 Amann U, Luger TA, Metze D. Lichenoid pseudolymphomatous
tattooing reaction. Hautarzt 1997; 48: 410–13.
11 Sowden JM, Cartwright PH, Smith AG et al. Sarcoidosis presenting
with a granulomatous reaction confined to red tattoos. Clin Exp
Dermatol 1992; 17: 446–8.
12 Kuperman-Beade M, Levine VJ, Ashinoff R. Laser removal of
tattoos. Am J Clin Dermatol 2001; 2: 21–5.
13 Kyanko ME, Pontasch MJ, Brodell RT. Red tattoo reactions:
treatment with the carbon dioxide laser. J Dermatol Surg Oncol
1989; 15: 652–6.
14 Zirkin HJ, Avinoach I, Edelwitz P. A tattoo and localised lymph-
adenopathy: a case report. Cutis 2001; 67: 471–2.