Dermatology Online Journal

Keratoacanthoma in a tattoo
Airton dos Santos Gon MD¹, Lorivaldo Minelli MD¹, Marcela Cristina Garbosa Meissner MD²
Dermatology Online Journal 15 (7): 9

1. Department of Dermatology, State University of Londrina, Parana, Brazil. airton@sercomtel.com.br
2. Private practice

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Abstract

Several malignant lesions have been reported in association with tattoos, including basal cell carcinomas, squamous cell carcinomas and melanoma. We report a keratoacanthoma arising in a recent tattoo. A 60-year-old woman presented with a tumor on her right leg, over an area of red pigment in a professional tattoo. Histological analysis confirmed the clinical diagnosis of keratoacanthoma. Although the association between malignancy and tattoos is very uncommon dermatologists and dermatologic surgeons should be attentive to this possibility.

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Introduction

Keratoacanthoma is a cutaneous neoplasm that commonly affects sun-exposed areas of elderly individuals. This tumor is typified by rapid growth that is often followed by spontaneous regression. The pathogenesis of keratoacanthoma is not completely understood, but the tumor is thought to originate from the pilosebaceous unit; most consider it a form of squamous cell carcinoma. There are some reports of keratoacanthoma arising over sites of trauma, burn scars, and sites submitted to cryotherapy for actinic keratosis [1]. Recently, the association of keratoacanthomas with tattoos has been reported [2, 3, 4].

We report the occurrence of a keratoacanthoma in a woman professionally tattooed four months before. We briefly discuss the etiology of the keratoacanthoma and review potential tattoo reactions as presented in the literature.

Clinical synopsis

A 60-year-old woman developed an asymptomatic nodule over a red-pigmented area of a tattoo; the nodule had grown rapidly over one month. The tattoo had been created four months earlier by a professional tattoo artist. On dermatological exam, there was a 12 mm red dome-shaped tumor, with smooth and well-demarcated limits. In the center, keratinous material filled a small depression.

Figure 1	Figure 2
Figure 1. Multicolor tattoo with a red dome-shaped tumor on the right leg Figure 2. Closer view showing that the tumor originated over red-pigmented area

It was localized on the lateral aspect of her right leg. The lesion was treated by complete excision. The diagnosis of keratoacanthoma arising in an exogenous pigmented area was confirmed by histopathological analysis.

Figure 3	Figure 4
Figure 3. Invagination of the epidermis with a central crater that is filled with eosinophilic keratinous material Figure 4. Red pigment in the dermis

Discussion

Permanent tattoos are formed through the injection of ink solids through the epidermis into the dermis. Tattoos are increasingly popular in today's society and, as a result, observed reactions within tattoos are likely to become more abundant [5]. These potential adverse local reactions include infections, hypersensitivity reactions to pigments, granulomas, keloids, and neoplasms.

According to Jacob [5], three main classes of tattoo-associated reactions can be distinguished in the English literature: allergic/granulomatous/lichenoid, inoculation/infection, and coincidental lesions. Damage to dermis, during pigment injection, can also induce a Koebner response in some patients. Different reaction patterns have been described in association with tattoos, such as granulomatous, perivascular lymphocytic inflammation and massive epidermal hyperplasia [6].

Concerning malignant neoplasms there are few reports of skin cancer arising in tattoo sites, including sporadic cases of basal cell carcinomas [7, 8], squamous cell carcinomas [9, 10], histiocytic lymphoma [11], and melanoma [12, 13, 14, 15, 16]. Despite these reports, the significance of the association between tattoo and skin cancer is not completely understood. Considering the increasing number of tattoos worldwide, a higher frequency of these associations would be expected.

We report the occurrence of a keratoacanthoma over a tattoo. Only four previous reports of this association were found in the literature. In two reports [2, 10] multiple eruptive keratoacanthomas were associated with a multicolor tattoo. Kleinerman et al. [3] describe the treatment of a keratoacanthoma, arising from a longstanding tattoo, using Mohs micrographic surgery and a rotation flap to preserve the integrity of the original tattoo design in an area of minimal skin laxity. Kluger et al. [4] reported a keratoacanthoma occurring within the red dye of a tattoo. In our patient, the site of origin of the keratoacanthoma was the red-pigmented area too. Red pigments are the commonest cause of delayed-type lichenoid tattoo reactions [17]. Histology typically shows extensive lichenoid basal damage, well away from the dermal pigment [17]. There are several pigments used in tattoos to create a red hue. These include cadmium selenide (cadmium red), mercury sulfide, azo dyes, and sienna (red ochre, ferric hydrate, ferric sulfate) [18]. It is often difficult to trace the exact composition of the pigment used in a specific tattoo.

Conclusion

This case report seeks to alert the reader that keratoacanthoma should be included in the list of cutaneous complications related to tattooing, specifically in red-pigmented areas. The diagnosis can be challenging;the histological differential diagnoses include pseudoepitheliomatous hyperplasia and other forms of squamous cell carcinoma. The clinical differential diagnosis would include lichenoid and granulomatous reactions. Removal of the entire area, thorough histological examination and careful follow up are mandatory in these cases.

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