Traumatic tattooing: case description and a comprehensive review of the therapeutic management

A 61-year-old man presented to our dermatology clinic for a routine full-body skin examination in August 2022. On physical inspection, the patient was noted to have an asymptomatic superficial diffuse dark blue to black cutaneous deposition on the stomach and right arm (Figures 1, 2, and 3). The patient stated that this injury occurred following a mine explosion during his time serving in the military over 20 years ago. Reportedly, no additional bodily organs were involved following the blast. No treatment was ever performed on the foreign bodies; however, the patient noted that pieces of the dark material would occasionally be expressed from the skin. He also stated that the plaques had not changed in color or texture since the injury. A thorough physical examination did not demonstrate any signs of chronic plumbism (lead poisoning), such as loss of memory or concentration, nausea, abdominal pain, loss of coordination, numbness or tingling in the extremities, slurred speech, anemia, teeth or gum changes, pallor, or lividity of the skin. Imaging for additional organ injury and retained material was completed at the initial event 20 years ago and did not demonstrate any additional systemic involvement. No further workup was completed at presentation to our clinic given the chronicity of the deposition and previously completed imaging. Therapeutic options were discussed with the patient including surgical removal of the material, but the patient was not bothered by the material and opted to continue with observation.

Figure 1:

Diffuse dark blue to black plaque located on the ventral forearm and hand.

Figure 2:

Diffuse dark blue to black plaque located on the stomach.

Figure 3:

Close-up view of the diffuse dark blue to black plaque located on the stomach.

Cutaneous traumatic tattooing from blast injuries presents a unique clinical challenge. There is no consensus to the therapeutic management of traumatic tattoo injuries. The clinician must utilize their clinical judgement and work with the patient to decide on the optimal treatment. Several therapies have been utilized with success including hydrosurgery, removal with fine-tip forceps, microsurgical dermabrasion, carbon dioxide (CO₂), diode, erbium, neodymium-doped yttrium aluminum garnet (ND:YAG), and ND:YAG Q-switched laser [1]. In the acute setting, aggressive scrubbing utilizing sponges, surgical scrub brushes, or wire brushes is the treatment of choice and should be done within 6 h but no later than 72 h [1]. This may be paired with utilizing a fine-tip forceps over the following days to remove larger particles. Hydrosurgery has also been implemented in the initial care of traumatic tattooing, with no complications at 2 weeks and no significant scarring at 6 months postoperatively [2]. This process involves utilizing a hydrosurgery device to irrigate the wound with sterile saline at a high velocity, and a vacuum is created upon decreasing velocity, which pulls the material back into the machine with the irrigation fluid [2]. Hydrosurgery allows for more precise removal of the debris when compared to mechanical dermabrasion [2]. Persistent, deeply embedded particles require removal by more invasive techniques such as surgical excision, cryosurgery, or electrosurgery. Lasers have also been utilized in persistent cases, yet they are contraindicated as therapy for gunpowder inclusion injuries [1]. Therefore, it is essential to obtain a thorough history of the type of blast injury and potentially obtaining a punch biopsy for histological examination of the particles before laser therapy. Laser therapy may have more reliable outcomes and reduced risk of hypertrophic scaring compared to dermabrasion [2]. Q-switched Nd:YAG lasers involve an intense short-pulse light that causes selective thermolysis with fragmentation of the particles without thermal damage to adjacent structures [2]. They are considered to be the first-line treatment option for traumatic tattooing after debridement has been performed [3]. CO₂ and Erbium:YAG lasers may also be utilized [3]. These fractional ablative lasers cause thousands of small channels in the skin that heal without scarring [3]. It is postulated that the lasers create an inflammatory process that causes active transdermal elimination of the debris similar to that seen in perforating dermatoses [2]. Therapeutic management with lasers has been shown to have more reliable outcomes and fewer side effects when compared with dermabrasion [2]. It is important to note that scarring is still a potential risk factor of laser therapy, and therefore combined laser therapy may improve cosmetic outcomes [4]. Q-switched lasers may be more painful, yet healing can be more rapid than the ablative fractional lasers [4]. Fractional ablative lasers may be more useful for larger debris that is too large for the phagocytic elimination process that follows q-switch laser therapy [4]. The combination of a q-switched ruby laser with an ablative fractional laser has been demonstrated to enhance the aesthetic outcome compared to utilizing the q-switched ruby laser alone [3].

We present a case of late-phase retained shrapnel injury resulting from a mine explosion. We utilize this case to highlight the unique cutaneous findings associated with this condition and to discuss the proper management in the various phases of injury. It is essential for clinicians to understand the various mechanisms of injury associated with this condition and the therapeutic modalities available to effectively and safely manage traumatic tattooing.