The art of tattooing continues to achieve recognition in the twenty-first century, albeit with accompanying hazards.1 Reported adverse reactions to tattoos include infections, tumors, and hypersensitivity, and granulomatous reactions.2 Numerous infectious brokers might contain tattoos, together with human papillomavirus (HPV), molluscum contagiosum, herpes simplex virus, hepatitis C virus, tuberculoid and nontuberculoid mycobacteria, and Staphylococcus aureus.2
Verruca vulgaris occasionally has been reported to develop in tattoos.3,4 Beforehand reported circumstances of verruca in tattoos to suggest a predilection for blue or black pigment.1-5 We report a case of verruca vulgaris occurring inside the red-inked areas of a tattoo that first appeared roughly 18 years after the preliminary tattoo placement.
A 44-year-old woman experienced erythema, induration, and irritation of a tattoo on the left leg of two years period. The tattoo initially was inscribed greater than 20 years prior. The patient had a history of type 2 diabetes mellitus and continual obstructive pulmonary disease. She reported no prior trauma to the realm, prior rash or irritation, or related adjustments to her different tattoos, including those with red ink.
The affected tattoo was inscribed at a separate time from the opposite tattoos. Physical examination of the irritated tattoo revealed hyperkeratotic papules with firm scaling in the zone of dermal red pigment (Figure 1). Notable nodularity or deep induration was not present. The clinical differential diagnosis included a hypersensitivity response to red tattoo ink, sarcoidosis, and an infectious course, akin to an atypical mycobacterial infection.
A punch biopsy demonstrated papillomatous epidermal hyperplasia with hyperkeratosis, focal parakeratosis, and frequent vacuolization of keratinocytes with enlarged keratohyalin granules, diagnostic of verruca vulgaris (Figure 2). Of note, the patient didn’t have clinically obvious viral warts elsewhere on physical examination. The patient was efficiently managed with a mix of two treatments of intralesional Candida antigen and three treatments of cryotherapy with the decision of most lesions over the course of 8 months.
Over the next several months, the patient utilized topical salicylic acid, which led to the decision of the remaining lesions. The verrucae had not recurred 19 months after the preliminary presentation.
The event of verruca vulgaris inside a tattoo might happen secondary to numerous mechanisms of HPV inoculation, including the introduction of the virus via contaminated ink, the tattoo artist’s saliva, autoinoculation, or koebnerization of a pre-existing verruca vulgaris.4 Native immune system dysregulation secondary to tattoo ink additionally has been proposed as a mechanism for HPV infection in this setting.1,5 The contents of darker tattoo pigments might promote the formation of reactive oxygen species inducing native immunocompromise.5
The pathogenic mechanism was elusive in our patients. Though the localization of verruca vulgaris to the zones of red pigment could also be merely coincidental, this phenomenon raised suspicion for direct inoculation through contaminated red ink. The patient’s different red ink–containing tattoos that were inscribed individually were spared, appropriate with contamination of the red ink used for the affected tattoo. Nevertheless, the delayed onset of almost 2 decades was distinctive, given the shorter beforehand reported latencies starting from months to 10 years.4 Autoinoculation or koebnerization is believable, although better involvement of nonred pigments could be anticipated in addition to a briefer latency. Finally, the potential for native immune dysregulation appeared possible, given the gradual evolution of the lesions largely restricted to one pigment sort.
We report a case of verruca vulgaris inside the red space of a multicolored tattoo that occurred roughly 18 years after tattoo placement. This case highlights an uncommon presentation of an infectious agent that will complicate tattoos. Each predilection for pink pigment slightly than black or blue pigment and the lengthy latency interval raised fascinating questions concerning pathogenesis. Confirmatory biopsy permits efficient administration of this tattoo complication.
- Huynh TN, Jackson JD, Brodell RT. Tattoo and vaccination sites: possible nest for opportunistic infections, tumors, and dysimmune reactions. Clin Dermatol. 2014;32:678-684.
- Wenzel SM, Rittmann I, Landthaler M, et al. Adverse reactions after tattooing: review of the literature and comparison to results of a survey. Dermatology. 2013;226:138-147.
- Trefzer U, Schmollack K, Stockfleth E, et al. Verrucae in a multicolored decorative tattoo. J Am Acad Dermatol. 2004;50:478-479.
- Wanat KA, Tyring S, Rady P, et al. Human papillomavirus type 27 associated with multiple verruca within a tattoo: report of a case and review of the literature. Int J Dermatol. 2014;53:882-884.
- Ramey Ok, Ibrahim J, Brodell RT. Verruca localization predominately in black tattoo ink: a retrospective case series. J Eur Acad Dermatol Venereol. 2016;30:E34-E36.