title: Diffuse Urticarial Reaction Associated with Titanium Dioxide Following Laser Tattoo Removal Treatments.
abstract: OBJECTIVE
  Local and generalized allergic reactions following laser tattoo removal have been documented, but are rare. To our knowledge, this is the fourth documented case of widespread urticarial eruptions following laser tattoo removal treatment. Unlike previously documented cases, this patient's reaction was found to be associated with titanium dioxide within the tattoo and her symptoms were recalcitrant to medical therapy.
  
  
  METHODS
  A 46-year-old female experienced diffuse urticarial plaques, erythema, and pruritis following multiple laser tattoo removal treatments with an Nd:YAG laser. The systemic allergic reaction was recalcitrant to increasing doses of antihistamines and corticosteroids. The tattoo was finally surgically excised. The excised tissue was analyzed by scanning electron microscopy and energy-dispersive X-ray analysis and contained high levels of titanium dioxide. Two weeks following the excision, and without the use of medical therapy, the patient had complete resolution of her generalized urticaria.
  
  
  CONCLUSIONS
  Ours is the first documented case of a diffuse urticarial reaction following laser tattoo removal treatments that shows a strong association to titanium dioxide within the tattoo pigment. Herein, we describe a novel surgical approach to treat recalcitrant generalized allergic reaction to tattoo pigment.
authors.affiliation: 1 Transitional Year Intern, Transitional Year Program, San Antonio Uniformed Services Health Education Consortium (SAUSHEC) , San Antonio, Texas.
authors.forename: Hal Bret
authors.initials: HB
authors.lastname: Willardson
authors.affiliation: 2 Dermatology Residency, San Antonio Uniformed Services Health Education Consortium (SAUSHEC) , San Antonio, Texas.
authors.forename: Todd T
authors.initials: TT
authors.lastname: Kobayashi
authors.affiliation: 2 Dermatology Residency, San Antonio Uniformed Services Health Education Consortium (SAUSHEC) , San Antonio, Texas.
authors.forename: Jason G
authors.initials: JG
authors.lastname: Arnold
authors.affiliation: 2 Dermatology Residency, San Antonio Uniformed Services Health Education Consortium (SAUSHEC) , San Antonio, Texas.
authors.forename: Chad M
authors.initials: CM
authors.lastname: Hivnor
authors.affiliation: 2 Dermatology Residency, San Antonio Uniformed Services Health Education Consortium (SAUSHEC) , San Antonio, Texas.
authors.forename: Casey D
authors.initials: CD
authors.lastname: Bowen
mesh_terms: D005260:Female; D006801:Humans; D053844:Lasers, Solid-State / Q000009:adverse effects*; D008875:Middle Aged; D013653:Tattooing; D014025:Titanium / Q000009:adverse effects*; D014581:Urticaria / Q000209:etiology*
chemical_list: C009495:titanium dioxide; D014025:Titanium
keywords: laser; management; reaction; tattoo removal; urticaria