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A 36-year-old construction worker described a 3-month history of bilateral pain, stiffness and swelling of the ankles and lower limb joints. Symptoms were worse in the mornings and were associated with generalised fatigue. He had no significant medical history and was taking regular naproxen only with no recorded drug allergies. On examination, cardiovascular and respiratory systems were normal. There was bilateral synovitis of the ankles. Of note, the patient had multiple small papules within the large tattoos on his upper limbs. The lesions were non-tender and were of the same colour as the underlying tattoo ink (figure 1).