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Acral skin atrophy in an infant: an early clue to Kindler syndrome diagnosis

and lymphadenopathy disappeared within 3 months and systemic corticosteroids gradually decreased. Tattoos can induce allergic reactions like type IV T-cell mediated hypersensitivity, or cutaneous lymphoid hyperplasia, more often on red ink tattoos. They can also induce granulomatous reactions due to foreign body reactions or authentic sarcoidosis. Cutaneous manifestations occur in about one-third of patients with systemic sarcoidosis. The development of SG in old scars, traumatised skin sites and around foreign material is well known and may represent a K€ obner phenomenon. SG can appear on tattoos and be limited to them. Since the first of sarcoidosis revealed by granulomas on tattoo described in 1952, several cases of SG on tattoos have been reported. SG occur whatever the ink of the tattoo: red (cinnabar), black (ferric oxide) and blue-black. They can appear while an alreadyknown systemic sarcoidosis with or without previous skin involvement. They may also be the only manifestation of sarcoidosis or reveal a systemic sarcoidosis even asymptomatic as in our patient. In most reported cases, SG on tattoos occur spontaneously but triggering by medication, such as interferon alpha has been reported. The skin lesions appear several weeks to several decades after tattooing. In our case, SG developed 10 years later. Such prolonged delay has been rarely reported. Histological differentiation between sarcoidosis and a foreign body reaction can sometimes be difficult and the two can be associated. However, if foreign material is discovered in granulomas, investigations for sarcoidosis should still be led. The cause of sarcoidal reactions in tattoos remains unknown. In genetically predisposed patients, the ink of the tattoos could induce a chronic antigenic stimulation, resulting in a Th1/Th2 immunity imbalance with a predominant Th1 immune response. The systemic spread of the tattoo pigment could induce the same reaction in other sites, causing systemic manifestations. Sarcoidosis must be hypothesized when nodular lesions arise on tattoos, along benign lymphoid hyperplasia, infectious inoculation. Skin biopsy is required and systemic sarcoidosis has to be ruled out, even in the absence of systemic symptoms.