10.5826/dpc.1203121
text/xml
2160-9381
1763
en
Pavithra Ayyanar
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
tattoo
Dermoscopy of pseudoepitheliomatous hyperplasia tattoo reaction pattern: A potential mimicker of squamous cell carcinoma
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2022-07-28
2021-04-25
2022-07-28
2022-09-15
e2022121
Dermatol Pract Concept
Pavithra Ayyanar
2022/07/28
10.5826/dpc.1203121
e2022121
Department of Pathology, AIIMS, Bhubaneswar, India
2160-9381
tattoo
en
e2022121
of granulomatous skin diseases. J Am Acad Dermatol. 2015;72 (1 Suppl):S60-S63. DOI: 10.1016/j.jaad.2014.07.059. PMID:25500047.
Dermoscopy of pseudoepitheliomatous hyperplasia tattoo reaction pattern: A potential mimicker of squamous cell carcinoma
https://dpcj.org/index.php/dpc/article/download/1763/1657
                    Dermatology Practical & Conceptual


Dermoscopy of Pseudoepitheliomatous Hyperplasia
            Tattoo Reaction Pattern
             Biswanath Behera1, Rashmi Kumari2, Debasis Gochhait3, Pavithra Ayyanar4


1 Department of Dermatology and Venereology, AIIMS, Bhubaneswar, India
2 Department of Dermatology, Venereology and Leprology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER),
  Puducherry, India
3 Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
4 Department of Pathology, AIIMS, Bhubaneswar, India



Keywords: dermoscopy, pseudoepitheliomatous hyperplasia, squamous cell carcinoma, tattoo
Citation: Behera B, Kumari R, Gochhait D, Ayyanar P. Dermoscopy of pseudoepitheliomatous hyperplasia tattoo reaction pattern.
Dermatol Pract Concept. 2022;12(3):e2022121. DOI: https://doi.org/10.5826/dpc.1203a121
Accepted: November 29, 2021; Published: July 2022
Copyright: ©2022 Behera et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License
(BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/ which permits unrestricted noncommercial use, distribution,
and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Rashmi Kumari, M.D., Associate Professor, Dept. of Dermatology, Venereology and Leprology, JIPMER,
Puducherry, Pin-605006. Phone no- 09489692199, Email: rashmi.sreerag@gmail.com




Introduction                                                             irregular vessels. The peripheral zone showed a gray-white
                                                                         to bluish-white structureless area (Figure 1, B and C). The
Delayed cutaneous tattoo reactions are a relatively rare oc-             differential diagnoses included were lupus vulgaris, tuber-
currence and include, lichenoid, granulomatous, allergic,                culosis verrucosa cutis (TBVC), chromoblastomycosis, and
pseudoepitheliomatous (PEH), and pseudolymphoma. Der-                    granulomatous tattoo reaction pattern. Histology showed
moscopic features of delayed tattoo reaction patterns are                hyperkeratosis,    parakeratosis,     pseudoepitheliomatous
rarely reported [1].                                                     hyperplasia, spongiosis, and lymphocytic exocytosis. In
                                                                         addition to tattoo pigment, the dermis had a subepider-
                                                                         mal band-like, perivascular and peri-adnexal predominant
Case presentation
                                                                         lymphocytic infiltration and occasional plasma cells. Also,
A 21-year-old male had a one-year history of a slow-grow-                the epidermis showed focal keratinocyte swelling, dysker-
ing, asymptomatic lesion over a blue tattoo. It started six              atotic cells, and the dermis showed an increased number
months after the tattooing. Cutaneous examination showed                 and dilated dermal blood vessels. (Figure 2, A and B). Other
solitary erythematous to bluish verrucous plaque over the                investigations were within normal limits. The diagnosis
tattoo (Figure 1A). Dermoscopic examination under non-                   of PEH tattoo reaction pattern was made, and the patient
polarized mode revealed two distinct zones. The central                  was treated with intralesional triamcinolone acetonide
area had white scales, white to pinkish-white structure-                 40 mg/ml.
less area, comedo-like opening with keratotic plugging,                       PEH is the result of benign hyperplasia of the epider-
white circles, red globules, hemorrhage, hairpin, and linear             mal and adnexal epithelium. Tattoo-induced PEH is a rare



Research Letter | Dermatol Pract Concept. 2022;12(3):e2022121                                                                           1
Figure 1. (A) Solitary erythematous to bluish verrucous plaque
over the tattoo. (B) Dermoscopic examination under nonpolar-
ized mode (HEINE DELTA20®, 10X magnification) shows white
scales, white to pinkish-white structureless area, comedo-like
opening with keratotic plugging, white circles (blue arrow), red
globules, hemorrhage, and linear irregular vessels (red arrow).     Figure 2. (A) Histology shows pseudoepitheliomatous epidermal
(C) The peripheral zone shows a gray-white to bluish-white struc-   hyperplasia (H & E, X100). (B) A subepidermal band-like, perivas-
tureless area and hairpin vessels (blue arrow). Red arrow points    cular and periadnexal, predominant lymphocytic infiltration, along
white circle.                                                       with tattoo pigments (H&E, X100).

benign reaction pattern commonly to red or purple pig-              tattoo or arise from the PEH. The early onset and lesions
ment. Differentiating PEH from squamous cell carcinoma              confinement to the tattoo margins favors PEH, while a
(SCC) is vital to reduce patient morbidity and cosmetic             late onset and involvement beyond the tattoo border sug-
disfigurement, as the latter can occur independently over           gest SCC.



2                                                                       Research Letter | Dermatol Pract Concept. 2022;12(3):e2022121
   A homogenous violaceous pattern with follicular                may help distinguish PEH from other differential diagnoses
white-yellow halo was reported in a case of tattoo pseudo-        described above, but not from SCC, in which case only clin-
lymphoma [1]. The dermoscopic features described for              ical and anamnestic data may help in their differentiation.
SCC are scales, keratin, white circles around a dilated and
plugged follicular infundibulum, white structureless area,
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Conclusions                                                           25500047.


We are reporting the clinico-dermoscopic-pathologic fea-
tures of a case of PEH tattoo reaction pattern. Dermoscopy




Research Letter | Dermatol Pract Concept. 2022;12(3):e2022121                                                                     3
