LAUSR

Dear Editor, Since Lubeck et al published the first article on tattoo complications in 1952, there have already been numerous articles on tattoo-related health problems. In the last 15 years, the tattoo trend in society has caused a real health alarm. Multiple complications have been described, including sarcoidosis. A 35 year-old man from the Dominican Republic was referred to our clinic for the recent appearance of an asymptomatic erythematous papule on a black ink tattoo made 3 years ago (Figure 1A), associated with multiple nonulcerated erythematous nodules in the nasal vestibule (Figure 1B). Endoscopy transnasal (ENT) examination showed a yellow-orange tumor in the cavum, whose histopathological study showed an inflammatory reaction with epithelioid granulomas without caseous necrosis. The polymerase chain reaction study for tuberculosis was negative. The blood test showed only a high angiotensinconverting enzyme (ACE, 97 U/L), with the rest of the study being normal. A full leather positron emission tomography—computed tomography (PET-CT) was performed showing symmetrical and intense uptake of the ganglion chains in the neck, chest, abdomen, and pelvis. Ophthalmological, cardiological, and pneumological examination was normal. Histopathological study of a groin adenopathy was performed, showing nonnecrotizing epithelial granulomatous lymphadenitis. With the described findings, the patient was diagnosed with systemic sarcoidosis. The patient started treatment with oral prednisone (1 mg/kg/d) associated with hydroxychloroquine 200 mg twice a day. At 3 months, the patient showed no improvement, so azathioprine was associated (2.5 mg/kg/d). At 3 months, the patient showed no improvement. Therefore, treatment with adalimumab was initiated (initial dose: 80 mg; maintenance dose: 40 mg every 14 days). The review after 3 months showed an almost complete clearance of the lesions (Figure 2A,B). Currently the patient is being treated with adalimumab (40 mg every 2 weeks), with a satisfactory control of the disease. Sarcoidosis is a systemic disease of unknown etiology that mainly affects internal organs such as the lung, and lymph nodes. Skin involvement may be the first sign leading to the diagnosis of the disease. The histopathological study is characterized by the presence of noncase-producing epithelioid granulomas. It is crucial to rule out other granulomatous processes such as tuberculosis or lymphoproliferative processes. The relationship between tattoos and