Pseudoepitheliomatous hyperplasia – an unusual reaction following tattoo: report of a case and review of the literature

Abstract

A 59-year-old woman presented with an itchy and uncomfortable raised lesion at a tattoo site (Fig. 1) on the lateral aspect of the left leg, just above the ankle. The tattoo had been placed 2 years before her presentation and the tattoo site was sun exposed. Immediately after she had the tattoo, she noticed redness of the skin. After a week, a pruritic and red scaly nodule developed that continued to gradually enlarge until her presentation. The patient had tried topical vitamin A and D ointment with no relief. The patient also had tattoos on the arms without any noticeable skin changes. The patient reported that the tattoo procedure on her leg was more painful than that on her arms, and was performed by a different (and perhaps inexperienced) tattoo artist. The original tattoo contained red, green, and yellow pigments. A diagnosis of tattoo granuloma was considered; squamous cell carcinoma and fungal infection were included in the differential diagnosis. A punch biopsy was performed, followed by complete surgical excision of the lesion with a split-thickness skin graft from the right thigh. The skin excision specimen showed a 3 x 2.5-cm granular and pitted pink lesion with well-demarcated, somewhat irregular borders. The lesion was raised 0.5 cm above the skin surface. The lesion was present in the center of the original tattoo. Portions of the original tattoo with green and blue-green pigmentation were visible on either side of the lesion. No satellite lesions were identified. Microscopically, the raised lesion demonstrated striking pseudoepitheliomatous hyperplasia, with irregular acanthosis of the epidermis and follicular infundibula, hyperkeratosis, and parakeratosis (Fig. 2). Follicular plugging was present with keratin-filled cystic spaces. There was a brisk mononuclear inflammatory infiltrate in the dermis, composed primarily of lymphocytes, with admixed plasma cells and histiocytes. Giant cells were occasionally identified. Dermal pigment deposition was noted both within the lesion and in the surrounding skin, corresponding to the original tattoo. Variable dermal fibrosis was noted, with thick collagen bundles in some areas. There was no evidence of epidermal keratinocytic atypia, dyskeratosis, or increased suprabasal mitotic activity. Special stains (periodic acid-Schiff and acid-fast) for microorganisms were negative.

Pseudoepitheliomatous Epidermal Hyperplasia in Tattoos

“…It may be of interest to note that different patterns may occur simultaneously on different tattoos of a single patient. [4] The occurrence of PH has rarely been reported in this setting and only within red [5][6][7][8] or purple [9] areas of tattoos to date. PH refers to a benign irregular hyperplasia of the epidermis that can also involve follicular infundibulum and acrosyringium.…”

A Rare Case of Pseudoepitheliomatous Hyperplasia of the Skin Arising in a Tattoo Site

“…Goldberg in 1959 (18), as multiple verrucous papules forming exclusively in the area of red tattoo ink. A few more cases of pseudoepitheliomatous hyperplasia were described later, where the authors reported various ways of adverse reaction development from the moment of ink application, lasting from four days to 12 months, with the process localization on forearms, back, and lower limbs (9,10,(19)(20)(21). The trigger effect of solar radiation on pseudoepitheliomatous hyperplasia development was observed (20,22,23).…”

“…A few more cases of pseudoepitheliomatous hyperplasia were described later, where the authors reported various ways of adverse reaction development from the moment of ink application, lasting from four days to 12 months, with the process localization on forearms, back, and lower limbs (9,10,(19)(20)(21). The trigger effect of solar radiation on pseudoepitheliomatous hyperplasia development was observed (20,22,23). Histopathological examination of the skin biopsy sample taken from a lesion shows epidermal and infundibular hyperplasia, signs of epidermal vacuolization and dyskeratosis, lymphocytic and histiocytic dermal infi ltration with red pigment gra nules more rarely -local areas of dermoepidermal junction damage (9).…”

A case of pseudoepitheliomatous hyperplasia to tattoos

“…These features consent the differential diagnosis by squamous cell carcinoma. 3,4 In literature, there are few cases of PEH to tattoos, but it is very important that clinicians be aware of this possibility and of the possible development of cutaneous cancer in the site of tattoo.…”