In vivo and ex vivo dermoscopy of lesions from implantation of human papillomavirus in tattoos: report of two cases,

AnBrasDermatol.2020;95(1):78---81

Anais

Brasileiros

de

Dermatologia

DERMATOPATHOLOGY

In

vivo

and

ex

vivo

dermoscopy

of

lesions

from

implantation

of

human

papillomavirus

in

tattoos:

report

of

two

cases

夽,夽夽

John

Verrinder

Veasey

_,

_Ana

_Luisa

_Nasser

_Erthal

_,

_Rute

_Facchini

_Lellis

a_{DermatologyClinic,IrmandadedaSantaCasadeMisericórdiadeSãoPaulo,SãoPaulo,SP,Brazil} b_{PathologyLaboratory,IrmandadedaSantaCasadeMisericórdiadeSãoPaulo,SãoPaulo,SP,Brazil}

Received6November2018;accepted12February2019 Availableonline17December2019

KEYWORDS Dermoscopy; Histology; Comparative; Tattooing; Warts

Abstract Thenumber ofindividualswithtattooshasbeenincreasing worldwide,alongside withreports ofcomplicationsvarying fromreactions totheinjected pigmentstoinfections causedbyagentsinoculatedinthepigmentationprocess.Thediagnosisofsuchunwantedevents canbeobtained throughcomplementarynon-invasivemethods,preserving themaximumof the tattoo design.The authors present two casesof patients withwarts on tattooing,and correlatetheirclinicalaspectstoinvivoandexvivodermoscopy,andtothefindings inthe histopathologicalexamination,aimingtodeterminepatternsthataidthediagnosisofthese lesionswithoutperformingbiopsy.

©2019SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.Thisisan openaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

The practice of skin ornamentation is a habit as old as humancivilization,havingbeenfoundinmummiesfromthe periodbetween2000and4000BC.1_{Currently,itisestimated}

that21% ofthe adult populationof theUnited Stateshas

夽 _{Howtocitethisarticle:VeaseyJV,ErthalAL,LellisRF.Invivo}

and ex vivo dermoscopy of lesions from implantation ofhuman papillomavirusintattoos:reportoftwocases.AnBrasDermatol. 2020;95:78---81.

夽夽_{Study conducted at the Dermatology Clinic, Irmandade da}

SantaCasadeMisericórdiadeSãoPaulo,SãoPaulo,SP,Brazil.

∗_{Correspondingauthor.}

E-mail:johnveasey@uol.com.br(J.V.Veasey).

at least onetattoo,2 _{and25% in Germany.}3 _{Regarding the}

Brazilian population, the prevalence of individuals with a tattoovariesfrom10%to26%inmenandfrom10%to22% inwomen.4

Duringthetattooingprocess,theindividualisexposedto histologicalreactionstothepigments(eczematous,sarcoid, granulomatous, pseudolymphomatous),4 _{as well as}

infec-tions caused by different pathogens, which can lead to severe sequelae and difficult treatment.1,2 _{Among these}

infections, there arereports of systemic diseases suchas hepatitis B, hepatitis C, and HIV infection,1 _{and those}

restricted totheskin, suchasatypicalmycobacterioses2,5

andwarts.6

https://doi.org/10.1016/j.abd.2019.02.008

0365-0596/©2019SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC BYlicense(http://creativecommons.org/licenses/by/4.0/).

Invivoandexvivodermoscopyoflesionsfromimplantationofhumanpapillomavirusintattoos 79

Figure1 (A)Clinicalaspectofthetattoowithmultiplepapulesarrangedlinearly.(B)Invivodermoscopy(×10magnification) showingpapuleswithdigitiformandreddottedprojectionscorrespondingtovascularectasias.(C)Exvivodermoscopy(×20 mag-nification)showingpapillomatousanddottedhemorrhagicprojectionsintheepidermis,withpresenceofpigmentinthesuperficial dermis.

Figure2 Histopathologicalexam ofpatient1,stainedwithhematoxylin&eosin.(A)_×40magnification,presentingepidermis withpapillomatosis, prominenthyperkeratosis withparakeratosis,hypergranulosis, acanthosis andelongated epidermalridges, anddermiswithpresenceofextracellulardepositsofblackpigment,compatiblewithexogenouspigment.(B)_×200magnification evidencingdetailofpapillomatosis.(C)×200magnificationwithdetailofblackpigmentaccumulationindermis.

This report presents two cases of patients who, after receivingatattoo, developed lesionsonthe pigmentation line,havingaclinical,dermatoscopic,andhistopathological diagnosisofwart.

Inthefirstcase,a39-year-oldmanwithatattooonthe leftsideoftheleftcalffor eightyearsreportedlocalized lesions on the tattoo for seven years. He denied contin-ued use of medications or use of topical medications on thelesions.Attheexamination,therewerenumerous ery-thematousscalingpapulesthatvariedbetween3and7mm indiameter,arrangedonthecontoursofthetattoo, form-inglinearpaths.Atdermoscopy,someprojectionsofsimilar diameter and length were observed in a ‘‘knob’’ pattern over thepapules,withthrombosedglomerular capillaries, givingtheappearanceofredspotsonthelesion’ssurface. An incisionalbiopsywith punchwasperformed and an ex vivodermoscopywasperformedforabetteranalysisofthe

cutaneousstructuresandtheiralterations.Apapillomatous verruciform appearance in the epidermis was presented, withunderlying pigmentinthedermis (Fig.1).The result ofhistopathologicalexaminationwascompatibletoawart overatattoo(Fig.2).

Inthesecondcase, a33-year-oldmanwithatattoo on theleftupperlimbfor 12yearsreportedlesionsthat dis-seminatedsixyearspreviouslyonthedesignofhistattoo.He waspositiveforHIVinfection,usingzidovudine,lamivudine, ritonavir,anddarunavir(viralloadundetectableandCD4+ cellscount:582/mm3_{)andgenitalcondylomataacuminate}

(multiple papillomatous warts), under treatment. Physi-calexamination showed a dermatosis located on the left armcharacterizedbymultipleflattenederythematousand confluentpapules,formingplaqueswithdefinedand irreg-ularborders.Somelesionsaccompaniedthetattoodesign, whileothersaffectedhealthy skin.Dermoscopypresented

80 VeaseyJVetal.

Figure3 (A)Clinicalappearanceofthetattoo,withmultiplediscreteanddiffuseerythematouspapules,bothonthetattooand onhealthyskin.(B)Invivodermoscopy(×10magnification)showingdetailsofthepapuleswithunspecificdesquamation,without digitiformprojectionsandreddots.(C)Exvivodermoscopy(_×20magnification)showingaslightlythickenedupperportionthe epidermiswithdiscreteflatpapillomatousprojections,associated withthepresenceofpigmentinthe superficialandmedium dermis.

Figure4 Histopathologicalexam ofPatient2, stained with hematoxylin&eosin. In (A)(_×200magnification)hyperkeratotic epidermiswiththepresenceofbalonizedkeratinocytesontheepidermalsurfaceisobserved.Inthedermis,thereareexogenous blackpigment depositsaround thevessels. In (B)(×400magnification), nuclear polymorphismand hyperchromiaareevident, inadditionto thebroadand basophiliccytoplasm ofkeratinocytes,characterizing thecytopathic effectofHPV. In (C)(×400 magnification),theblackpigmentofthetattoodepositedaroundthevesselsisobserved.

a nonspecific appearance, with isolated spots of desqua-mation.Anincisionalbiopsy wasperformed, andasinthe firstcase,anexvivodermoscopyofwasperformed,showing aslightlythickenedepidermiswithdiscretepapillomatosis andpresenceofpigmentinthedermis(Fig.3).Theresultof thehistopathologicalexamination confirmedthe diagnosis ofawartoveratattoo(Fig.4).

Reportsofskincontaminationfromthetattooingprocess have increased in recent years, from infectious bacterial diseases suchas atypical mycobacterioses andleprosy, to viralinfectionssuchaswartsandmolluscumcontagiosum, andtodiseases transmittedbysexuallytransmitted infec-tionsuchassyphilis.Suchanincreasehasstimulatedajoint action of theUnited StatesFood and DrugAdministration withtheCentersforDiseaseControlandPreventiontorevise thehealthsurveillancecriteriafortattoocenters.Another importantstepwastheeducationofhealthprofessionalsfor

therecognitionandappropriatetreatmentofinfectionsand cutaneousreactionsintattoos.2

Wartsarefrequentskinconditionscausedbythehuman papillomavirus(HPV),aDNAvirusofuniversaldistribution.7

Dysfunction intheepithelial barrierdue totrauma causes microscopicdisruptionsintheskin,allowingviral transmis-sion.Inthecasespresented,therewasdamagetotheskin barrier during tattooing, with possible inoculation of the virus duringtheprocess.3 _{Viralwartsinthe affectedarea}

mayariseafteran incubationperiodthatgenerallyranges from three weeks to eight months.7 _{In some cases, the}

latencyperiodislonger,andmayreachtenyears,makingit difficulttorelatetheonsetofthelesiontodirectinoculation throughtheprocedure. Inthesecases,itis proposedthat the developmentof wartswould depend ondysregulation oftheimmunesystem,8_{sincecell-mediatedimmunityplays}

Invivoandexvivodermoscopyoflesionsfromimplantationofhumanpapillomavirusintattoos 81 beevidencedinthesecondpatientwithHIV,whopresented

moreextensiveandpersistentlesions.

In a review of wart implantation on tattoos, it was observed that the risk of acquiring a wart on black pig-mentis seven-foldgreater thanoncolored pigmentor on non-tattooed skin.6 _{In the first case here reported, the}

patienthadnocomorbiditiesandpresentedwartsrestricted tothe tattoo, while the second patientpresented lesions thatdidnotrespectthepigmentlinearity,includinghealthy skin.

Dermoscopy was of greatvalue in the reported cases. Aspectsclassicallypresentincommonandanogenitalwarts wereobservedinthelesionsonthetattoospresentedhere inthefirstcase,9,10_{makingpossiblethediagnosisofthe}

HPV-inducedlesion,evenoverthepigment.Inthesecondcase,it washardertoidentifysuchdermatoscopicfeatures,which werealsorareintheclinicalpresentation.Sequencingfor HPVinthiscasewouldbeveryworthwhiletobetter char-acterizeifthelesionisabeta-papillomavirus,andwhether theHPVofthecondylomaacuminataisthesameasthatof thetattoo. However,itwasnotpossibletocarryoutsuch analysis.

Another illustrative aspect of this study is the ex vivo

dermatoscopy,whereitwaspossibletoidentifyboththe epi-dermalalterationscaused byHPVandthedermal changes producedbythepresenceoftattoopigment.Thesefindings werecompatiblewiththoseidentifiedinthe histopatholog-icalexamination.

Theimportanceofthepresentstudyisitsdescriptionof theclinical, dermoscopic,and histologicalaspectsofHPV infection associated withtattoos, as well as the findings of exvivodermatoscopy similartothoseidentifiedin the histopathologicalexamination.The authorsemphasize the importanceoftheclinicalsuspicionofHPVinfection, man-ifestedbytheappearanceofwartsaftertattooing,andthe needtoadoptpublichealthmeasuresthatmakethis proce-duresafer,inordertoavoidfutureevents.

Financial

support

Nonedeclared.

Authors’

contribution

JohnVerrinderVeasey:Approvalofthefinalversionofthe manuscript;conceptionandplanningofthestudy; elabora-tionandwritingofthemanuscript;obtaining,analyzing,and interpretingthedata;effectiveparticipationinresearch ori-entation;intellectualparticipationinpropaedeuticand/or

therapeuticconductofthecasesstudied;criticalreviewof theliterature;criticalreviewofthemanuscript.

AnaLuisaNasserErthal:Conceptionandplanningofthe study;elaborationandwritingofthemanuscript;obtaining, analyzing,andinterpretingthedata;criticalreviewofthe literature;criticalreviewofthemanuscript.

Rute Facchini Lellis: Obtaining, analyzing, and inter-pretingthedata;intellectualparticipationinpropaedeutic and/ortherapeuticconductofthecasesstudied.

Conflicts

of

interest

Nonedeclared.

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