A years-long ordeal for a tattooed Polish man who underwent multiple surgeries to excise every last chunk of red-inked skin highlights the severe allergic reactions tattoo pigments can trigger in some people.
The man in his thirties went through a barrage of assessments, treatments, and surgeries before doctors could make sense of his "unusual constellation" of symptoms, which first started appearing about four months after he got inked on his right forearm.
A red, itchy rash spread across the man's arms and chest, then worsened into erythroderma, a severe, widespread skin inflammation. Doctors thought this was linked to eczema until "eruption-like changes" appeared specifically in the man's red-pigmented skin immediately after he stopped taking medication.
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In the years following his tattoo, the man also lost the ability to sweat, shed all his body hair, and developed vitiligo, a skin-lightening condition.
An allergy specialist recommended that the man have the inflamed fragments of his forearm tattoo surgically removed, after which the skin changes gradually receded.
Only once the red tattoo ink was completely removed, and he was given immunosuppressive drugs, did his overall condition improve. His hair grew again, and the progression of his vitiligo halted, although the damage to his sweat glands remains, with a slim chance of them working again.
Extreme cases like this are rare, yet some surveys suggest that around 6 percent of people experience systemic reactions or persistent health problems after tattooing, and up to 67 percent report skin reactions of varying severity.
"In light of this case, there is a growing recognition of the need for regulations governing tattoo ink composition, as well as education aimed at both tattoo artists and the public regarding the safety of tattooing," the man's doctors, from Wroclaw Medical University in Poland, write in their case report.
In 2022, two years after the Polish man got inked, the European Union introduced regulations on the composition of tattoo inks to restrict the use of dangerous chemicals. However, in many countries, regulations still do not exist.
The medical team was unable to obtain a sample of the red ink from the man's tattoo artist, so they couldn't test it for toxic and carcinogenic substances commonly found in red tattoo pigments, such as mercury and synthetic azo dyes.
Tattooing is an ancient practice with rich cultural traditions and artistic flair, but practices have changed, and concerns about commercial tattoo inks are growing with our understanding of how pigments injected deep into the skin move through the body and accumulate in lymph nodes, activating immune cells that can't clear the insoluble ink.
Related: Study Links Tattoos to 29% Higher Risk of Dangerous Skin Cancer
Recent testing also shows that many tattoo inks contain compounds that aren't listed on the label, making it even more difficult, if not impossible, to pinpoint what causes some allergic reactions.
In this case, the team suspects that the red tattoo ink, whatever it contained, triggered an exaggerated response in the man's immune system, which was already sensitive due to an existing autoimmune condition.
Skin biopsies from the man's hands and left armpit revealed that few sweat glands remain, even in his untattooed skin.
"Patients with some autoimmune diseases, like our patient with Hashimoto's thyroiditis, should be particularly cautious when deciding to get a tattoo," the team writes, noting that reactions to red inks have been reported in people with atopic dermatitis, asthma, and celiac disease.
With his inability to sweat persisting, the Polish man is at risk of heat stroke. He uses a water spray bottle to stay cool, but cannot exercise or work as he once did.
The case report has been published in Clinics and Practice.