Sarcoid reaction in eyebrow tattooing: a complication of a common cosmetic procedure

herapeutic conduct of the studied cases; effective paricipation in research orientation; critical review of the anuscript. Renato Shintani Hikawa: Approval of the final version of he manuscript; collection, analysis and interpretation of ata; design and planning of the study; intellectual paricipation in propaedeutic and/or therapeutic conduct of tudied cases; effective participation in research orientaion; critical review of the manuscript.

A 30-year-old female patient, with a history of previous bariatric surgery, without other comorbidities, complained of raised eyebrows for three months. She had repeatedly undergone micropigmentation of the region over the past four years, the last being 14 months before. She denied any systemic symptoms. On examination, she had raised plaques on the topography of the eyebrows, especially on the right, in addition to areas of alopecia ( Fig. 1A). At dermoscopy, homogeneous orange-brown areas and rarefied hairs were seen (Fig. 2). The remainder of the physical examination was normal. Complementary tests including serum calcium level, electrocardiogram, chest X-ray, serum protein electrophoresis, and tuberculin skin test were normal.
Histopathology showed non-caseating chronic granulomatous dermatitis with a sarcoid pattern (Fig. 3); acid-fast bacillus (AFB) and fungal tests were negative. With the diagnosis of sarcoid reaction secondary to the tattooing of the eyebrows, therapy with doxycycline 100 mg/day and fludroxycortide occlusive treatment was performed for 15 days. The patient missed the reassessment appointment and returned after three months with complete regression of the  (Fig. 1B). She was advised not to repeat the procedure.
Micropigmentation is normally performed with a portable tattoo pen, which is smaller than the traditional tattoo device. Ready-made paints are available on the market, but some professionals make their own mixtures. Pigment washout may occur during the first few days of healing, then the remaining pigment particles are stored in dermal macrophages and fibroblasts. 2,3 Sarcoid granulomas can develop in areas of tattooing or permanent makeup as isolated reactions or as part of systemic sarcoidosis. The time between the tattoing and the reaction onset is variable, and there may be a long latency period, justifying the investigation of systemic sarcoidosis. 1 Topical and intralesional corticosteroids are the first line of treatment. 1 Studies suggest that tetracyclines inhibit granuloma formation, and their role in the treatment of sarcoid reactions has been documented. 4 There are also reports of systemic treatment with allopurinol and antimalarials. 5 The patient had an excellent response after a short period of treatment with occlusive corticosteroids associated with doxycycline, with no lesion recurrence to date.
While numerous cases of sarcoid granulomas have been reported in body tattoos, few have been related to eyebrow micropigmentation. With the greater prevalence of this cosmetic technique, it is important to recognize the possible adverse reactions, as well as the adequate management. Moreover, it is crucial to remember the importance of investigating systemic sarcoidosis in these patients.

Financial support
None declared.

Authors' contributions
Tamires Ferri Macedo: Approval of the final version of the manuscript; drafting and editing of the manuscript; collection, analysis, and interpretation of data; critical review of the literature.
Simone Perazzoli: approval of the final version of the manuscript; drafting and editing of the manuscript; collection, analysis, and interpretation of data; critical review of the literature.
Renan Rangel Bonamigo: Approval of the final version of the manuscript; design and planning of the study; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the manuscript.
Renata Heck: Approval of the final version of the manuscript; design and planning of the study; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the manuscript. A 13-year-old Chinese boy presented with a segmental hypopigmented patch on his left abdomen and back following the Blaschko line since birth. Since the age of 10, comedones, scattered red papules, pustules, and nodules developed on the hypopigmented patch ( Fig. 1A-B). Dilated follicular ostia with keratin plug, less pigmented terminal hairs with abnormal curled growth pattern, and follicle-centered hypomelanosis were identified under the Dermoscopy examination (Fig. 1C). During early childhood the patient had a minor delay in mental development and an attention deficit disorder, but no solid evidence of mental deficiency was found when he presented. The patient's general health status, magnetic resonance imaging scan, skeletal X-Ray, and routine laboratory examinations were normal. Their family history was unremarkable.

Conflicts of interest
Venous blood was taken from the patient and his parents, and skin biopsies from the lesional and normal skin of the patient were performed. Histological examination showed dilated plugged follicular infundibula and perifollicular lymphohistiocytic infiltrate (Fig. 1D). Sanger sequencing of FGFR2 (NM 022970) detected the heterozygous mutation c.758C>G in exon 7 in the affected skin (Fig. 1E) 3 reported a severe case in a patient presenting with multiple segments involved. Ma et al. 4 described a similar case but not confirmed by gene investigation. In addition, some documented nevus comedonicus cases with hypopigmentation may be the same disease. 5 Acneiform lesions are the primary feature of this entity. FGFR2 mutation in keratinocytes could induce the hypercornification of the pilosebaceous duct and inflammatory response. 2 The p.Pro253Arg mutation is located in the highly conserved linker region of FGFR2 and leads to liganddependent FGFR2 activation in vivo due to a conformational change that increases ligand-binding affinity. 3 Extensive acneiform lesions, and depigmentation of hair, skin and eyes have been described in Apert syndrome in which twothirds of patients exhibit a germline FGFR2 mutation. 6 The acneiform lesions responded to treatment with isotretinoin 20 mg daily like those in Apert syndrome. 3,6 The presence of early-onset hypopigmentation is another persistent characteristic feature reported in almost all published cases except the first case in which whether there was pigmentation change was not mentioned. It could be caused by the failure of melanosome transfer from melanocytes to keratinocytes or by elevated IL-1␣-mediated postinflammatory hypopigmentation. 2 Based on clinical and molecular data of these published cases, here, the authors propose that 'segmental hypopigmented acneiform nevus with FGFR2 mutation' might be a more comprehensive description for this specific entity. In addition, the authors suggest any atypical nevus comedonicus with a feature of hypopigmentation and/or inflammatory lesion should consider this disorder and bear in mind that postzygotic mosaicism for a genetic disease such as Apert syndrome can also affect the gonads, thus resulting in a risk of transmission to offspring. 6