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JAMA Dermatology Clinicopathological Challenge
February 2016

Painful and Pruritic Papules in the Gray Shading of a Tattoo

Author Affiliations
  • 1University of Kentucky College of Medicine, Lexington
  • 2University of Arkansas for Medical Sciences College of Medicine, Little Rock
  • 3Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania
JAMA Dermatol. 2016;152(2):205-206. doi:10.1001/jamadermatol.2015.3448

A 31-year-old, otherwise healthy woman presented with a 2-month history of an erythematous eruption on her right ventral forearm. Multiple painful, pruritic papules and pustules developed 1 week after the addition of gray shading to the original tattoo (Figure, A and B). She had previously seen her primary care physician and had been treated unsuccessfully with a 2-week course of trimethoprim-sulfamethoxazole, a 2-week course of prednisone, and topical triamcinolone acetonide. Results from a routine wound culture were negative for organisms. Five other customers of the same tattoo artist had recently complained of a similar erythematous eruption. Physical examination revealed firm, red papules and pustules with slight crusting confined within the areas of gray shading in the tattoo. Punch biopsies of the lesions were performed (Figure, C and D).