Tinea and Tattoo: A Man Who Developed Tattoo-Associated Tinea Corporis and a Review of Dermatophyte and Systemic Fungal Infections Occurring Within a Tattoo
Cureus. 2022 Jan 13;14(1):e21210. doi: 10.7759/cureus.21210. eCollection 2022 Jan.
Fungal infections may occur within tattoos. These include not only dermatophyte infections (tattoo-associated tinea) but also systemic mycoses (tattoo-associated systemic fungal infections). The PubMed search engine, accessing the MEDLINE database, was used to search for all papers with the terms: (1) tinea and tattoo, and (2) systemic fungal infection and tattoo. Tattoo-associated tinea corporis has been observed in 12 individuals with 13 tattoos; this includes the 18-year-old man who developed a dermatophyte infection, restricted to the black ink, less than one-month after tattoo inoculation on his left arm described in this report. Tattoo-associated tinea typically occurred on an extremity in the black ink. The diagnosis was established either by skin biopsy, fungal culture, and/or potassium hydroxide preparation. The cultured dermatophytes included Trichophyton rubrum, Epidermophyton floccosum, Microsporum canis, Microsporum gypseum, and Trichophyton tonsurans. Several sources for the tinea were documented: autoinfection (two patients), anthrophilic (tinea capitis from the patient’s son), and zoophilic (either the patient’s cat or dog). Three patients presented with tinea incognito resulting from prior corticosteroid treatment. Tinea appeared either early (within one month or less after inoculation during tattoo healing) in six patients or later (more than two months post-inoculation in a healed tattoo) in six patients. Injury to the skin from the tattoo needle, or use of non-sterile instruments, or contaminated ink, and/or contact with a human or animal dermatophyte source are possible causes of early tinea infection. Tattoo ink-related phenomenon (presence of nanoparticles, polycyclic aromatic hydrocarbons, and cytokine-enhancement) and/or the creation of an immunocompromised cutaneous district are potential causes of late tinea infection. Treatment with topical and/or oral antifungal agents provided complete resolution of the dermatophyte for all the patients with tattoo-associated tinea. Tattoo-associated systemic fungal infection has been reported in six patients: five men and one patient whose age, sex, immune status, and some tattoo features (duration, color, and treatment) were not reported. The onset of infection after tattoo inoculation was either within less than one month (two men), three months (two men), or 69 months (one man). The tattoo was dark (either black or blue) and often presented as papules (three men) or nodules (two men) that were either individual or multiple and intact or ulcerated. The lesion was asymptomatic (one man), non-tender (one man), or painful (one man). The systemic fungal organisms included Acremonium species, Aspergillus fumigatus, Purpureocillium lilacinum, Saksenaea vasiformis, and Sporothrix schenckii. Contaminated tattoo ink was a confirmed cause of the systemic fungal infection in one patient; other postulated sources included non-professional tattoo inoculation, infected tattooing tool and/or ink in an immunosuppression host, and contaminated ritual tattooing instruments and dye. Complete resolution of the tattoo-associated systemic fungal infection occurred following systemic antifungal drug therapy. In conclusion, several researchers favor that tattoo inoculation can be implicated as a causative factor in the development of tattoo-associated tinea; however, in some of the men, tattoo-associated systemic fungal infection may have merely been coincidental.