Tattoo Sarcoidosis: Report of 2 cases and Review of the literature

We report 2 cases of cutaneous sarcoidosis developing in response to tattoo pigments.Our first case explores aseptic microabscess formation precipitated by the interplay of systemic sarcoidosis and repeated intralesional steroid injections over tattoo sites.Our second case explores tattoo sarcoidosis as an indicator of inadequate medical therapy for treatment of systemic sarcoidosis.A 71-year-old Chinese female patient developed bilateral eyebrow rash, itch, and swelling over the site of eyebrow embroidery which was done 18 months prior.A dermatopathological examination revealed noncaseating granulomas consistent with cutaneous sarcoidosis.She was started on monthly intralesional steroids injection which were complicated by painful erosions and crusting over both eyebrows.A repeated biopsy showed aseptic microabscesses with sarcoid-type granulomas.An acute flare of cutaneous sarcoidosis was diagnosed and the rashes improved with a 3-month course of oral hydroxychloroquine.Shortly after, she started to experience altered coloured vision.Ocular sarcoidosis was diagnosed after FFA (fundus fluorescein) and ICG (indocyanine green) angiography, and the patient was started on oral prednisolone.Our second case is a 36-year-old Indian male who was diagnosed with systemic sarcoidosis 5 years prior when an endomyocardial biopsy and FDG PET thorax scan revealed myocardial and pulmonary sarcoidosis respectively.He was started on a tapering dose of oral prednisolone.6 months later, on a tapered prednisolone dosage of 2.5mg per day, he presented with painless and pruritic papules delineating the tattoos over his chest and left arm done 3 years prior.Dermatopathological examination showed non-necrotizing granulomas consistent with cutaneous sarcoidosis.The patient would develop steroid-dependent tattoo sarcoidosis, reporting painful swelling and itch of his tattoos each time oral prednisolone was stopped or tapered.Weekly methotrexate injections were initiated in place of oral prednisolone which lead to a resolution in his symptoms.