ANAIS BRASILEIROS DE DERMATOLOGIA SEPTEMBER/OCTOBER 2022 V. 97 N. 5| 551–696 LUPUS MILIARIS DISSEMINATES FACIEI WITH EXTRA-FACIAL INVOLVEMENT IN A 6-YEAR-OLD JAPANESE GIRL M. Kusano et al Official publication of the Brazilian Society of Dermatology Dermatologia Anais Brasileiros de Volume 99 Number 4 2024 www.anaisdedermatologia.org.br Tattoos: risks and complications, clinical and histopathological approach Are behavioral interventions a better choice for atopic dermatitis patients? A meta-analysis of 6 randomized controlled trials Efficacy and safety of 0.5% colchicine cream versus 5% 5-fluorouracil cream in the treatment of cutaneous field cancerization: a randomized clinical trial Follicular unit grafting in chronic ulcers: a valuable technique for integrated management Efficacy of 5% topical minoxidil versus 5 mg oral biotin versus topical minoxidil and oral biotin on hair growth in men: randomized, crossover, clinical trial Secondary syphilis occurring under anti-CD20 therapy: risks, progression and approach Low-dose oral minoxidil for persistent chemotherapy and radiotherapy-induced alopecia in a pediatric female patient JULY/AUGUST 2024 V. 99 N. 4| 489–650
Volume 99. Number 4. July/August 2024 CONTENTS Editorial Anais Brasileiros de Dermatologia: on the eve of its centennial year ............................................................. 489 Silvio Alencar Marques, Ana Maria Roselino, Hiram Larangeira de Almeida Junior, Luciana Patrícia Fernandes Abbade Continuing Medical Education Tattoos: risks and complications, clinical and histopathological approach ....................................................... 491 David Chalarca-Cañas, Mario A. Caviedes-Cleves, Luis A. Correa-Londoño, Juan Pablo Ospina-Gómez, Margarita M. Velásquez-Lopera Original Article Are behavioral interventions a better choice for atopic dermatitis patients? A meta-analysis of 6 randomized controlled trials .........................................................................................................................................503 Wenying Zhong, Wei Li, Guangsheng Wu Assessment by the Scheimpfl ug imaging system of corneal clarity and anterior segment properties in rosacea patients ...... 513 Erman Bozali, Duygu Yalınbaş Yeter, Mustafa Tosun, Anıl Selim Apa Association of sociodemographic and clinical factors with the quality of life of Brazilian individuals with Neurofi bromatosis type 1: a cross-sectional study ........................................................................................................... 520 Natália Parenti Bicudo, Carla Maria Ramos Germano, Roberta Teixeira de Moraes, Lucimar Retto da Silva de Avó, Rosalie E. Ferner, Débora Gusmão Melo Effi cacy and safety of 0.5% colchicine cream versus 5% 5-fl uorouracil cream in the treatment of cutaneous fi eld cancerization: a randomized clinical trial ............................................................................................. 527 Amanda Soares Teixeira, Ivanka Miranda de Castro Martins, Anna Carolina Miola, Hélio Amante Miot Expression analysis and biological regulation of silencing regulatory protein 6 (SIRT6) in cutaneous squamous cell carcinoma ................................................................................................................................... 535 Sai Chen, Hongxia Chen, Xu Wang, Dongmei Zhang, Li Zhang, Jiawei Cheng, Qi Zhang, Zhixiang Hua, Xu Miao, Jian Shi Targeted therapy for immune mediated skin diseases. What should a dermatologist know? .................................. 546 Edinson López, Raúl Cabrera, Cristóbal Lecaros Special Article Follicular unit grafting in chronic ulcers: a valuable technique for integrated management ................................. 568 Anahi Belatti, Florencia Bertarini, Virginia Pombo, Luis Mazzuoccolo, Damian Ferrario Letter – Research Dermoscopy as an auxiliary tool for the diagnosis of acral squamous diseases: palmoplantar psoriasis, tinea pedis/manuum and eczema ................................................................................................................................. 578 Mariana Vieira Martins Sampaio Drummond, Jules Rimet Borges, Ana Maria Quinteiro Ribeiro, Bárbara Alvares Salum Ximenes
Effi cacy of 5% topical minoxidil versus 5mg oral biotin versus topical minoxidil and oral biotin on hair growth in men: randomized, crossover, clinical trial .................................................................................................... 581 Flávia de Oliveira Valentim, Anna Carolina Miola, Hélio Amante Miot, Juliano Vilaverde Schmitt Erythroderma: clinical and etiological study of 88 cases seen in a tertiary hospital over 25 years ........................... 584 Rogério Nabor Kondo, Betina Samesima e Singh, Milene Cripa Pizatto de Araújo, Victória Prudêncio Ferreira, Jessica Almeida Marani, Airton dos Santos Gon Insulin inhibits melanoma tumor growth through the expression of activating transcription factor 4, without detectable expression of transcription factor CHOP: an in vivo model ......................................................................... 587 Daniel do Prado, Marianna Boia-Ferreia, Hanna Camara da Justa, Andrea Senff-Ribeiro, Sérgio Lunardon Padilha Predicting skin graft failure on the scalp by intraoperative laser speckle analysis .............................................. 591 André Pinho, Ana Brinca, Carolina Figueiredo, Duarte Flor, Ricardo Vieira Prognostic factors and survival of patients with melanoma treated at a reference hospital in the Brazilian Amazon region ........................................................................................................................................ 594 Amanda Gabay Moreira, Antonio Vitor da Silva Freitas, Carla Andrea Avelar Pires Stiff skin syndrome: long-term follow-up .............................................................................................. 597 Jessica Lana Conceição e Silva Baka, Tauana Ogata Coelho da Rocha, Marcella Soares Pincelli, Luciana Paula Samorano, Maria Cecília da Matta Rivitti-Machado, Zilda Najjar Prado de Oliveira Letter – Clinical A novel ATP2C1 mutation (c.1840-1G>A) in a sporadic case of isolated perianal Hailey-Hailey disease with human papillomavirus type 58 infection ........................................................................................................ 601 Yao Zhu, Yi-Ming Fan, Yan-Xia Cai, Yong-Hua Chen, Fang Qiu Amelanotic melanoma with neural lesion simulating leprosy ....................................................................... 603 Andrezza Telles Westin, Sebastião Antônio de Barros Junior, Cacilda da Silva Souza Autosomal dominant monilethrix with incomplete penetrance due to a novel KRT86 mutation in a Chinese family ...... 606 Ru Dai, Tingting Wang, Xianjie Wu Dermoscopy of nasal and auricular gouty tophi ....................................................................................... 609 Bruno Simão dos Santos, Maria Augusta Pires Maciel, Neusa Yuriko Sakai Valente Familiar white sponge nevus ............................................................................................................. 613 Camino Prada-García, Asunción González-Morán, Xenia Pérez-González Löfgren’s syndrome manifestation of acute sarcoidosis: short-term resolution with association of anti-infl ammatory drugs .... 615 Rebecca Perez de Amorim, Ana Flávia Teixeira de Abreu, Aline Garcia Lutz, Vinícius Cardoso Nóbrega, Ivanka Miranda de Castro, Hélio Amante Miot Lupus miliaris disseminatus faciei with extra-facial involvement in a 6-year-old Japanese girl .............................. 618 Misaki Kusano, Maki Takada, Natsuko Matsumura, Toshiyuki Yamamoto Paraneoplastic acquired ichthyosis as the fi rst manifestation in breast implant-associated anaplastic large cell lymphoma ................................................................................................................................... 621 Héctor Chiang Wong, Pilar Martínez Sánchez, María del Carmen González Guzmán Letter - Dermatopathology Pigmented eccrine syringofi broadenocarcinoma simulating malignant melanoma .............................................. 625 Bianca Cristina Dantas, Luana Rytholz Castro, Natália Scardua Mariano Alves, Bethânia Cabral Cavalli Swiczar, Neusa Yuriko Sakai Valente Letter - Tropical/Infectious and Parasitic Dermatology Overdosage of PPD immunotherapy causing tuberculosis-like skin lesions ....................................................... 629 John Verrinder Veasey, Victória Cerqueira Elia, Ana Estela Ribeiro, Rute Facchini Lellis
Secondary syphilis occurring under anti-CD20 therapy: risks, progression and approach ...................................... 632 Luiz Augusto Fabricio de Melo Garbers, Tissiana Marques de Haes, Cacilda da Silva Souza Letter – Therapy Low-dose oral minoxidil for persistent chemotherapy and radiotherapy-induced alopecia in a pediatric female patient ...... 635 Raíssa Rodriguez Melo, Rita Fernanda Cortez de Almeida, Luciana Rodino Lemes, Sidney Frattini Junior, Paulo Müller Ramos, Daniel Fernandes Melo Mesalamine-induced photosensitivity – A case report and literature review ..................................................... 637 Svetlana Popadic, Igor Kapetanovic, Aleksandra Sokic-Milutinovic Oral isotretinoin for the treatment of chronic pityriasis versicolor: case report and literature review ..................... 639 John Verrinder Veasey, Gustavo de Sá Menezes Carvalho, Guilherme Camargo Julio Valinoto Pityriasis rubra pilaris after COVID-19 vaccination: successful treatment with ustekinumab .................................. 642 Bárbara Vieira Granja, Patrícia Amoedo, Nuno Preto Gomes, Catarina Costa, Filomena Azevedo, Sofi a Magina Successful treatment of rheumatoid neutrophilic panniculitis with tofacitinib .................................................. 644 Hiram Larangeira de Almeida Junior, Vitor Dias Furtado, Viviane Siena Issaacson, Ana Letícia Boff Terbinafi ne as a successful treatment in primary cutaneous aspergillosis ........................................................ 647 Juan-Manuel Morón-Ocaña, Isabel-María Coronel-Pérez, Elena-Margarita Rodríguez-Rey
Anais Brasileiros de Dermatologia 2024;99(4):489- 490 Anais Brasileiros de Dermatologia www.anaisdedermatologia.org.br EDITORIAL Anais Brasileiros de Dermatologia: on the eve of its centennial year The Anais Brasileiros de Dermatologia (ABD), published for the first time in January 1925 as Annaes Brasileiros de Dermatologia e Syphilographia, already had as proposal its bimonthly publication, which was not always possible; however, its publication has been occurring uninterruptedly since then. From 1983 onward, under the direction of Prof. Rubem David Azulay, the ABD definitively consolidated itself as a modern, bimonthly publication with an emphasis on original articles. Since its creation, it has been maintained with the financial support of the Brazilian Society of Dermatology (Sociedade Brasileira de Dermatologia, SBD), making use, over time, of the selfless work, in succession, of the Scientific Editors (Chief Editor and Associate Editors), Reviewers and National and International authors. Although it is not the oldest Dermatology journal in the Americas or even in South America, it is certainly one of the most recognized, due to its practically constant advancement, consolidated by its indexing in LILACS since 1981, SciELO since 2003 and in PubMed/Medline since 2009. The ABD has, philosophically, provided space to infectious and endemic dermatological diseases, either tropical or not, ancient or not, still prevalent, and which affect a significant part of the Brazilian population,1- 4 including original subjects and new technologies.5,6 It is one of the rare journals with open access and no cost for authors, whether Brazilian or foreign. But there are challenges to be overcome, both in the present and in the future, which must be addressed in the next issues so that they can be discussed and collectively defined, even if controversial. For instance, keeping the journal in print and online? Only the online version? Exclusively in English? In issues or continuous flow? Advance the discussion on the financing of publication Study conducted at the Department of Infectology, Dermatology, Imaging Diagnosis and Radiotherapy, Universidade Estadual Paulista, Botucatu, SP, Brazil. fees with shared costs? These are the most pressing questions. And why should they be discussed? It is suggested that readers consult the articles in references 7 and 8, which emphasize the importance of the metrics that evaluate and rank scientific journals and that reinforce the importance of discussing the items suggested above.7,8 At present, it is our responsibility as the ABD, SBD, and their Associates to prepare the celebrations of 100 years of publication, which the ABD certainly deserves. And, the certainty that, in addition to the congratulations that the ABD will receive, we also await achievements resulting from discussions on the issues listed above. We invite Associates and the National and International Editorial Boards to share their ideas and suggestions so that the ABD, in its centenary year, is highlighted among contemporary scientific journals in the dermatological universe. Financial support None declared. Authors’ contributions Silvio Alencar Marques: Approval of the final version of the manuscript; drafting and editing of the manuscript. Ana Maria Roselino: Approval of the final version of the manuscript; drafting and editing of the manuscript. Hiram Larangeira de Almeida Junior: Approval of the final version of the manuscript; drafting and editing of the manuscript. Luciana P. Fernandes Abbade: Approval of the final version of the manuscript; drafting and editing of the manuscript. Conflicts of interest None declared. https://doi.org/10.1016/j.abd.2024.04.001 0365-0596/© 2024 Sociedade Brasileira de Dermatologia. Published by Elsevier Espan˜a, S.L.U. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
EDITORIAL References 1. Orofino-Costa R, Freitas DFS, Bernardes-Engemann AR, Rodrigues AM, Talhari C, Ferraz CE, et al. Human sporotrichosis: recommendations from the Brazilian Society of Dermatology for the clinical, diagnostic and therapeutic management. An Bras Dermatol. 2022;97:757- 77. 2. Montanha JOM, Nardi SMT, Binhardi FMT, Pedro HSP, Santi MP, Paschoal VDA. ML Flow serological test: complementary tool in leprosy. An Bras Dermatol. 2023;98: 331- 8. 3. Cestari SCP, Cestari MCP, Marques GF, Lirio I, Tovo R, Labriola ICS. Cutaneous manifestations of COVID-19 patients in a Hospital in São Paulo, Brazil, and global literature review. An Bras Dermatol. 2023;98:466- 71. 4. Moraes PC, Eidt LM, Koehler A, Ransan LG, Scrofeneker ML. Epidemiological characteristics of leprosy from 2000 to 2019 in a state with low endemicity in southern Brazil. An Bras Dermatol. 2023;98:602- 10. 5. Tavares GT, Morato IB, Wainstein AJA. 90-degree incision in Mohs micrographic surgery for eyelid margin tumors -Is there a benefit? An Bras Dermatol. 2023;98:115- 7. 6. Braga JCT, Barcaui CB, Pinheiro AM, Sortino AMF, Abdalla CMZ, Campos-do-Carmo G, et al. Reflectance confocal microscopy - Consensus terminology glossary in Brazilian Portuguese for normal skin, melanocytic and non-melanocytic lesions. An Bras Dermatol. 2024;99:100- 10. 7. Marques SA, Roselino AMF, Almeida Jr HL, Abbade LPF. Anais Brasileiros de Dermatologia: metrics related to 2022 and position in the ranking of Dermatology journals. An Bras Dermatol. 2024;99:1- 2. 8. Miot HA, Criado PR, Castro CCS, Ianhez M, Talhari C, Müller-Ramos P. Bibliometric evaluation of Anais Brasileiros de Dermatologia (2013- 2022). An Bras Dermatol. 2024;99:90- 9. Silvio Alencar Marques a,∗, Ana Maria Roselino b, Hiram Larangeira de Almeida Junior c,d, Luciana Patrícia Fernandes Abbade a a Department of Infectology, Dermatology, Imaging Diagnosis and Radiotherapy, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil b Department of Clinical Medicine, Division of Dermatology, Faculty of Medicine of Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil c Department of Dermatology, Universidade Federal de Pelotas, Pelotas, RS, Brazil d Department of Dermatology, Universidade Católica de Pelotas, Pelotas, RS, Brazil ∗Corresponding author. E-mail address: silvio.marques@unesp.br (S.A. Marques). 6 April 2024 490
Anais Brasileiros de Dermatologia 2024;99(4):491- 502 Anais Brasileiros de Dermatologia www.anaisdedermatologia.org.br CONTINUING MEDICAL EDUCATION Tattoos: risks and complications, clinical and histopathological approach David Chalarca-Can˜as a,∗, Mario A. Caviedes-Cleves b, Luis A. Correa-London˜o a, Juan Pablo Ospina-Gómez a, Margarita M. Velásquez-Lopera a a Department of Dermatology, School of Medicine, University of Antioquia, Medellín, Colombia b Department of Pathology, School of Medicine, University of Antioquia, Medellín, Colombia Received 24 June 2023; accepted 23 July 2023 Available online 22 March 2024 KEYWORDS Complications; Inks; Punctures; Skin; Tattooing Abstract Background: Skin modification through tattoos is as old as humanity itself. However, this trend is on the rise, and with the use of different types of pigments and application practices, both cutaneous and systemic complications can arise. Adverse reactions can be grouped into five classes: inflammatory, infectious, neoplastic, aesthetic, and miscellaneous. On histopathology, inflammatory reactions can exhibit a lichenoid pattern or present as spongiotic dermatitis, granulomatous reactions, pseudolymphoma, pseudoepitheliomatous hyperplasia, or scleroderma/morphea-like changes. This article reviews tattoo complications, including their clinical and histopathological characteristics. Methods: An open search was conducted on PubMed using the terms ‘‘tattoo’’, ‘‘complications’’, and ‘‘skin’’. No limits were set for period, language, or publication type of the articles. Results: Reactions to tattoos are reported in up to 67% of people who get tattooed, with papulonodular and granulomatous reactions being the most common. Some neoplastic complications have been described, but their causality is still debated. Any pigment can cause adverse reactions, although red ink is more frequently associated with them. Patients with pre-existing dermatoses may experience exacerbation or complications of their diseases when getting tattoos; therefore, this procedure is not recommended for this patient group. Conclusions: Dermatological consultation is recommended before getting a tattoo, as well as a histopathological examination in case of complications. In patients who develop cutaneous inflammatory reactions following tattooing, additional studies are recommended to investigate systemic diseases such as sarcoidosis, pyoderma gangrenosum, atopic dermatitis, and neoplasms. It is important for physicians to be trained in providing appropriate care in case of complications. © 2024 Sociedade Brasileira de Dermatologia. Published by Elsevier Espan˜a, S.L.U. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). Study conducted at the University of Antioquia, Medellin, Colombia. ∗ Corresponding author. E-mail: david.chalarca@udea.edu.co (D. Chalarca-Can˜as). https://doi.org/10.1016/j.abd.2023.07.004 0365-0596/© 2024 Sociedade Brasileira de Dermatologia. Published by Elsevier Espan˜a, S.L.U. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
D. Chalarca-Can˜as, M.A. Caviedes-Cleves, L.A. Correa-London˜o et al. Introduction Definition Permanent tattooing is a practice carried out for aesthetic purposes that involves modifying the color of the skin. There are different types of cosmetic tattoos, which are applied through micropigmentation in various areas of the body, such as the eyes, cheeks, lips, and eyebrows, among others. Their objective may be to simulate makeup or camouflage dermatological conditions such as vitiligo, alopecia, and surgical scars. Additionally, three-dimensional tattooing of the areola and nipple is also used as the final stage in reconstructive breast surgery.1- 3 History The practice of tattooing has a long history dating back over 5000 years, and the term comes from the Tahitian word ‘‘ta-tau’’, which means ‘‘the results of tapping’’. The earliest evidence of tattooing was found on Ötzi, the iceman discovered in the Italian-Austrian Alps in 1991, who had over 50 charcoal tattoos on his arthritic joints. It is believed that the earliest tattoos had therapeutic purposes.4 Although the practice spread throughout Europe, it was prohibited by Emperor Constantine with the arrival of Christianity, and other religions such as Judaism and Islam did not accept it either. However, during oceanic expeditions in the 17th century, tattooing was reintroduced to Western civilization and became a symbol of wealth among the upper classes in the 19th century. C.H. Fellows is considered one of the first professional tattoo artists, and it was in 1870 in New York that the first tattoo studio was opened by Martin Hildebrant, a German immigrant. His major competitor was Samuel O’Reilly, who invented the tattoo machine in 1891, inspired by a device created by Thomas Edison. By around 1900, tattoo studios existed in almost every major city. At that time, tattoos were mainly used by bohemians from the underworld and circus artists and remained dormant to the public until the 1970s when tattooing became increasingly accepted by both sexes and all ages. Nowadays, it has become a fashion trend and is done for decorative purposes, enjoying great popularity in various cultures and age groups. Despite improvements in hygiene and sterilization practices, the reporting of adverse reactions is increasing due to the use of other components in tattoo ink.5 Methods An open search was conducted on PubMed without restrictions on date, language, or publication type to gather information on the dermatological complications of tattoos. The search terms used were ‘‘tattoo’’, ‘‘complications’’, and ‘‘skin’’. Articles dealing with systemic complications related to tattoos were excluded. Additionally, some articles and local sources of information from Latin America and Colombia were reviewed. Some clinical and histopathological images of tattoo-associated skin complications were included, obtained from a Dermatology Department in Colombia with prior patient consent. Results and discussion In the initial PubMed search using the term ‘‘tattoo’’, 6,359 results were found. However, when using more specific search terms like ‘‘tattoo’’, ‘‘complications’’, and ‘‘skin’’, the article set was limited to 391. Furthermore, some references to articles and local information from Latin America and Colombia on tattoo complications were incorporated. After reviewing the articles, 80 of them met the objectives of the search and were included in the review. Epidemiology The practice of tattoos mainly occurs in adolescents and young adults but has gained popularity across all age groups. The prevalence of tattoos varies significantly among different regions of the world, and there is no official data indicating the percentage of the global population with tattoos. According to surveys conducted by statistics portals like Statista, approximately 30% of Americans have tattoos. In Colombia, a polymeric survey conducted by the portal Cifras y Conceptos in 2020 revealed that 6% of the population over 35 years old has tattoos, while 19% of Colombians between 25 and 34 years old and 47% of people between 18 and 24 years old have tattoos. It has been found that up to 23% of patients who get a tattoo are not satisfied with the result.1 With the increase in tattooing practice, there is a growing number of adverse reactions, which are often seen by doctors but are less known to the public. Usually, these adverse reactions do not endanger life but can significantly affect the quality of life and cause disfigurement. Some studies describe that up to 2.1% of patients who get tattoos experience some type of complication,6 but it is believed that the actual rate may be higher due to underdiagnosis, as many people do not seek medical advice or self-medicate. In fact, some studies have reported rates as high as 67% of adverse skin reactions.7 The most used color in tattoos is black, but adverse reactions more commonly occur in response to red ink. Green ink is less frequently implicated in tattoo reactions, but it has been reported to worsen cutaneous reactions in patients during patch testing.5 Regulation in Colombia and the world Although the pigments used in tattoo inks must be approved by the Federal Food, Drug, and Cosmetic Act before being marketed, the Food and Drug Administration (FDA) has not regulated their use due to the priority of other public health issues and the lack of evidence of specific safety problems related to these pigments. The FDA classifies tattoo inks as cosmetics and takes measures to prevent safety issues and evaluate the severity of adverse events and the safety of pigments in case safety problems are identified. 492
Anais Brasileiros de Dermatologia 2024;99(4):491- 502 In Colombia, the regulation of tattooing practice follows the same requirements as cosmetic establishments, according to Resolution 2263 of 2004 by the Ministry of Health of Colombia. The regulation is limited to opening, operation, biosafety, and training requirements but does not extend to the surveillance of adverse events related to tattoo inks.8,9 Tattoo ink Inks are suspensions that contain metallic salts and organic compounds in a liquid vehicle such as water, alcohol, and glycerin. In the past, inks were rich in metallic salts, such as mercury sulfide, which was responsible for many adverse reactions. Currently, these components are still present but in smaller amounts. The components vary depending on the color of the ink. Black ink contains zinc oxide and carbon; white ink contains lead carbonate, titanium dioxide, barium sulfate, and zinc oxide; red ink contains mercury sulfide (cinnabar), cadmium selenide (cadmium red), sienna earth, ferric hydrate (red ochre), and organic dyes; brown ink contains iron oxide (ochre); yellow ink contains cadmium yellow, ochre, turmeric yellow, and chrome yellow; green ink contains chromium oxide, lead chromate, phthalocyanine dyes, ferrocyanides, and ferricyanides; blue ink is composed of cobalt blue, cobalt phthalocyanine, and cobalt aluminate; purple ink contains ammonium and manganese pyrophosphate, aluminum salts, and dioxazine/carbazole.10,11 Currently, many of these components are being replaced by azoic pigments (used in printers or automobile paint) because they are more colorful and resistant to fading.12 However, they may contain impurities such as aromatic amines.13 Antimony, cadmium, lead, chromium, cobalt, nickel, and arsenic may be present as contaminants.14 Inorganic metal salts or vegetable pigments mixed with cigarette ashes or other types of inks are used by inexperienced amateur tattoo artists, with a higher risk of adverse events.15 Most of the components used in permanent tattoos are toxic, mutagenic, or carcinogenic. As a result, adverse reactions can occur with a wide range of manifestations that may appear immediately or years after the tattoo placement.16 Superficial henna tattoos only dye the stratum corneum without introducing pigment into the dermis. These tattoos contain additives such as lemon juice or beet, walnut shell, sugar, and paraphenylenediamine, which accelerate the fixation process and improve the tattoo’s duration, lasting 1- 3 weeks.17,18 Pathophysiological mechanism The mechanism involves the disruption of the cutaneous barrier through the repetitive application of needles manually or by electric machines, followed by the deposition of exogenous colored particles below the dermo-epidermal junction at a depth of 1- 3 mm, reaching the papillary and reticular dermis. The rupture of superficial capillaries during the punctures causes mild bleeding that mixes with the ink. The colored particles are poorly soluble and highly resistant to enzymatic degradation, which perpetuates their presence in the dermis. The disruption of the basal membrane and necrosis of some dermal and epidermal cells leads to an acute inflammatory response during the first two hours of the procedure, where polymorphonuclear cells phagocytize the pigment. This clinically manifests as transient edema. At 24 hours, the pigment accumulates in the cytoplasmic phagosomes of keratinocytes, histiocytes, mast cells, and fibroblasts. During the first month of the procedure, before the regeneration of the basal membrane, part of the pigment is eliminated transepidermally and can be found in keratinocytes, macrophages, and fibroblasts. During this healing phase, some pathogenic microorganisms can infect the skin. Once the basal membrane has regenerated, no further transepidermal elimination occurs, reducing the risk of infectious complications. After the host’s acute response, a reaction to the foreign material (ink) occurs, initially involving a cell-mediated immune response, histologically characterized by a dense lymphocytic inflammatory infiltrate in the dermis. Larger particles do not transport to other anatomical sites and become residents of the dermis, where they are sequestered by mononuclear cells, fibroblasts, and extracellular tissue. Smaller ink particles penetrate deeper into the dermis and are recognized by Langerhans cells, which eventually transport them to the lymph nodes, generating a reactive lymphocytic response. Clinically, this presents as lymphadenopathy, and histologically, it is represented by the presence of pigment in the lymph nodes with abundant histiocytes and Langerhans cells in the paracortex (dermatopathic lymphadenopathy).5,19,20 Exaggerated or dysregulated responses, as well as the presence of toxic substances, generate the complications mentioned below. Clinical manifestations Adverse cutaneous reactions can occur in various forms, including edema, allergic reactions, itching, local pain, erythema, bleeding, papule formation, nodules, intense pain, and, rarely, neoplasms. Additionally, temporary hennabased tattoos can cause acute eczematous reactions that progress to depigmentation, hypertrophic scars, or more severe lichenoid reactions.21 Categorically, these reactions can be divided into five groups: inflammatory, infectious, neoplastic, aesthetic, and miscellaneous. Inflammatory reactions are further histopathologically categorized into a lichenoid pattern, spongiotic dermatitis, granulomatous pattern, pseudolymphoma, pseudoepitheliomatous hyperplasia, and sclerodermiform/morpheaform pattern, among others.16 In a systematic review, it was found that among all complications associated with tattoos, granulomatous reactions accounted for 48.48%, infectious reactions for 21.21%, and allergic reactions for 12.12%.22 Inflammatory complications Transient edema Transient edema is an inevitable reaction, and it is considered that up to a third of tattooed individuals may experience this minor complication.23 It manifests as induration of the tattooed area and may or may not be accompanied by pruritus, disorders in skin pigmentation, and focal dermal hemorrhagic disorders, among others, which self-resolve within a period of 2 to 3 weeks after pigment injection. These manifestations may result from 493
D. Chalarca-Can˜as, M.A. Caviedes-Cleves, L.A. Correa-London˜o et al. the trauma of hundreds of needle punctures, irritation from alcohol use, or an acute inflammatory reaction to the ink and/or diluent, leading to disruption of the epidermal basal membrane and some necrosis of dermal and epidermal cells.24,25 Allergic/Immune-mediated reactions Allergic contact dermatitis is characterized by eczematous, hyperkeratotic, or ulcer-necrotic lesions in the tattooed area, which may be photosensitized due to alteration of pigments through Ultraviolet (UV) decomposition or haptenization of antigens. Haptenization occurs when UV light affects the pigments and alters their chemical composition, making them recognizable as foreign substances and triggering an immune response. This can result in erythematous, vesicular, or exfoliative eruptions.26 Despite the transition to azoic-based inks, hypersensitivity reactions in tattoos are still primarily attributed to the presence of mercury in red inks.16,27 Regarding other ink colors, confirming the responsible allergen is difficult to achieve through patch testing due to the lack of precise lists of ingredients and comparable allergens for testing, and the results are often negative.28 This reinforces the idea that ink haptenization is a necessary step in the pathogenesis of adverse reactions.28 It is important to note that the main differential diagnosis for this reaction is pseudolymphoma, which often affects more than one color of the tattoo.16 Chronic skin diseases Tattoos can trigger the appearance of new lesions in individuals with preexisting dermatoses. These lesions typically appear a few days to weeks after the tattoo, although they can also extend for several months.29 Chronic skin diseases such as psoriasis, vitiligo, granuloma annulare, lichen planus, lichen sclerosus, pyoderma gangrenosum, lupus erythematosus, morphea, and Darier’s disease share a common characteristic: cutaneous manifestations can be reproduced in areas of focal trauma (Koebner’s isomorphic phenomenon).5,27 Patients with atopic dermatitis may develop contact allergy and photosensitivity reactions that trigger eczematous reactions or worsen exacerbations.27 Similarly, patients with preexisting pyoderma gangrenosum have been reported to develop ulcers resembling this condition at the tattoo site, especially in the lower extremities, due to the pathergy phenomenon.30,31 It is important to consider the recommendation that patients with preexisting dermatoses abstain from getting tattoos or be evaluated by a dermatologist before doing so, due to the potential risk of exacerbating the underlying pathology. Papulonodular reactions These occur months or years after the tattoo and are primarily associated with foreign body-type reactions, with approximately 29.3% of cases being associated with cutaneous or systemic sarcoidosis (Fig. 1). Granulomatous skin reactions associated with tattoos can be an initial presentation of a systemic disease like sarcoidosis, requiring additional studies such as chest radiography or computed tomography and laboratory tests.32 The mechanism of sarcoidosis induction in individuals with tattoos could be pigment overload, which can occur at the edges or corners of Figure 1 Papulonodular lesions following cosmetic eyebrow tattooing. The final diagnosis was sarcoidosis. Photographic archive of the Dermatology Service at the University of Antioquia. Figure 2 Papulonodular lesions over a black and red tattoo in the lower lumbar region. The histopathological diagnosis was pseudolymphoma. Photographic archive of the Dermatology Service at the University of Antioquia. a tattoo where pigment density is higher than in other areas, or in cases where there is repeated introduction of foreign material. This could lead to chronic immune system exposure to tattoo ink, resulting in sustained foreign body-type granulomatous inflammation and subsequent development of focal autoimmunity in genetically susceptible individuals for sarcoidosis development. This explains the oftenprolonged latency period between tattoo placement and the appearance of clinical symptoms.33,34 Sarcoidosis has been detected in tattoos of patients who have been treated with interferon for any reason. For this reason, it is suggested that individuals with a history of sarcoidosis avoid tattooing if they are being treated with interferon. Asymptomatic or pruritic indurated erythematous-violet papules and nodules on the tattooed area (Fig. 2) can also occur secondary to lichen planus, pseudolymphomas, lymphomatoid papulosis, lymphomas, among others, with the diagnosis confirmed through histopathology.35 Vasculitis The relationship is not clear; however, isolated cases of hypersensitivity vasculitis have been reported. It is impor494
Anais Brasileiros de Dermatologia 2024;99(4):491- 502 Figure 3 Lichenoid pattern. Epidermal hyperplasia, orthokeratosis, Malpighian layer with spongiosis and scattered dyskeratocytes. Vacuolar damage of the basal layer. In the dermis, there is an inflammatory infiltrate in a band-like pattern with some cytoid bodies containing black pigment, (Hematoxylin & eosin, [A] ×100, [B] ×400). Photographic archive of the Dermatopathology Laboratory, Dermatology Section, University of Antioquia. Figure 4 Spongiotic dermatitis. Preserved thickness of the epidermis with marked spongiosis and some dyskeratocytes. Basal vacuolar damage. Black ink pigment is identified in the dermis, (Hematoxylin & eosin, [A] ×100, [B] ×400). Photographic archive of the Dermatopathology Laboratory, Dermatology Section, University of Antioquia. tant to rule out other causes of vasculitis such as infection, medications, malignancy, or systemic diseases.36 Histopathological classification of inflammatory complications from tattoos Lichenoid inflammatory pattern It is the most common hypersensitivity tissue reaction that can occur in response to any ink color, but with a predilection for red ink due to the presence of components such as nickel, mercury, and cadmium, presenting even as verrucous lesions.37 Lichenoid reactions can be caused by lichen planus or overlap with allergic reactions, and sometimes it is difficult to distinguish between these two etiologies, making clinical correlation crucial. Sometimes the lichenoid inflammatory pattern is associated with the Koebner isomorphic phenomenon in patients with undiagnosed lichen planus, so when it is found, other anatomical sites should be examined.38,39 Histopathologically, it is characterized by a band-like lymphocytic dermal inflammatory infiltrate with interface changes, basal vacuolar degeneration, and dyskeratotic keratinocytes40 (Fig. 3). Spongiotic dermatitis This reaction can be found in the acute presentation following the tattoo (transient edema) or can be the manifestation of an allergic response. Histopathologically, it is characterized by intercellular epidermal edema (eczema) accompanied by a mixed or non-mixed chronic lymphocytic dermal inflammatory infiltrate, which can overlap with the lichenoid pattern 41,42 (Fig. 4). Granulomatous inflammatory pattern An inflammatory infiltrate composed of epithelioid histiocytes, multinucleated giant cells with variable lymphocytic and polymorphonuclear infiltrate, which can organize into different patterns, of which foreign body granuloma and sarcoidal granuloma are the most common. Foreign body granulomas are characterized by pigment495
D. Chalarca-Can˜as, M.A. Caviedes-Cleves, L.A. Correa-London˜o et al. Figure 5 Granulomatous inflammation of a sarcoid type. (A) Papulonodular lesions in a tattoo on the right scapular region. (B) Granulomatous infiltrate of sarcoid type associated with black ink pigment (Hematoxylin & eosin, ×400). Systemic studies revealed sarcoidosis. Photographic archive of the Dermatopathology Laboratory, Dermatology Section, University of Antioquia. laden foreign body-type giant cells. Sarcoidosis is defined by non-caseating epithelioid granulomas with little or no accompanying inflammatory response43 (Fig. 5). Staining and/or cultures should be performed to rule out fungal or mycobacterial infection. Granulomas with central necrosis (tuberculoid) are mainly observed in tuberculosis and leprosy, although they have also been described in response to ferric oxide and chromium salts in cosmetic tattoos. Granuloma annulare and necrobiosis lipoidica-like reactions are rarer.16,27,38 In one described case, a disease similar to Rosai-Dorfman was observed with a dense lymphocytic and histiocytic inflammatory infiltrate in the dermis. Abundant histiocytes with emperipolesis of inflammatory cells were found. However, unlike Rosai-Dorfman disease, there was no involvement of lymph nodes, which is a characteristic finding of that disease.44 Pseudolymphoma Pseudolymphoma is a clinically benign reaction characterized histopathologically by dense nodular dermal lymphocytic infiltrates or band-like lichenoid infiltrates. Immunohistochemical studies may show the presence of B- and T-cells with a normal immunophenotype, and gene rearrangement studies will reveal polyclonal lymphocyte populations.45 The pathogenesis is uncertain; however, it has been reported to occur frequently in areas of tattoos with red ink, which induces chronic antigenic stimulation resulting in polyclonal proliferation of B- and T-lymphoid cells. Although malignant transformation is rare, cases of B-cell lymphomas associated with tattoos have been described, so close follow-up is recommended. The differential diagnosis includes allergic reactions, B-cell and T-cell lymphomas, lymphomatoid papulosis, and infections.46,47 Pseudoepitheliomatous hyperplasia It is a reactive pattern characterized by marked epidermal hyperplasia accompanied by follicular hyperkeratosis and variable dermal inflammation composed of lymphocytes and plasma cells.48 It can be triggered by stimuli such as chronic irritation, scarring, trauma, and nonspecific inflammatory or infectious dermatoses, presenting between 2 weeks to 3 months after tattooing and should be differentiated from neoplastic entities such as keratoacanthoma and squamous cell carcinoma.49 Scleroderma/Morphea-like pattern Characterized by dermal sclerosis and/or dermal fibrosis, which can be secondary to an underlying connective tissue disease or represent the development of dermal fibrosis in a setting of chronic inflammation or hypersensitivity50 (Fig. 6). Other described histopathological patterns include psoriasiform, vasculitic, and neutrophilic dermatosis. Infectious complications Due to the disruption of the skin’s physical and immune barrier and the alteration of the cutaneous ecosystem, tattoos facilitate the inoculation of pathogenic microorganisms into the dermis, increasing the risk of infectious complications, especially in immunosuppressed patients. In informal settings with poor hygiene, the risk is higher. Infections can be of bacterial, viral, fungal, mycobacterial, and, more rarely, parasitic origin. Because of this, in some countries, according to local laws and regulations, individuals with tattoos are prohibited from donating blood for periods ranging from 4 months to 1 year after getting a tattoo. In Colombia, the minimum time is 6 months.51 When the technique is performed by an experienced professional tattoo artist using hygienic and sterile techniques, on healthy skin with proper post-procedure care, the risk is very low.6 Bacterial infections Bacterial infectious complications have been estimated to affect 1%- 5% of tattooed individuals.14 The most frequently 496
Anais Brasileiros de Dermatologia 2024;99(4):491- 502 Figure 6 Sclerodermiform/morphea-like pattern. The epidermis appears unaltered in thickness. In the dermis, fibrosis with effacement of cutaneous appendages is observed, associated with deposition of black ink pigment, (Hematoxylin & eosin, [A] ×100, [B] ×400). Photographic archive of the Dermatopathology Laboratory, Dermatology Section, University of Antioquia. reported ones include impetigo, folliculitis,52 furunculosis, abscesses, ecthyma, cellulitis, erysipelas, and gangrene, with the main causative agents being Staphylococcus aureus, Streptococcus pyogenes, Clostridium difficile, and Pseudomonas aeruginosa.53 Clinical manifestations typically appear within days to a few weeks after getting the tattoo and may include local pain, erythema, edema, fever, and, in some cases, purulent discharge. Some studies have reported that up to 28% of tattoo ink bottles are improperly sealed, and 10% may be contaminated with both pathogenic and non-pathogenic bacteria, posing a significant risk of adverse reactions to this practice.54 Transmission of syphilis through tattoos is anecdotal and was described in the past because of contamination with saliva from syphilitic tattoo artists. There have also been reported cases of secondary syphilis in tattooed areas, although these are currently rare.55,56 Generally, bacterial infections are easily treatable, and the treatment does not significantly differ from that of other infectious conditions.16 Mycobacterial infections Non-tuberculous mycobacteria are ubiquitous in water and can infect tattoo inks when gray ink is prepared by diluting black ink with non-sterile or non-distilled tap water. Additionally, ink dilution reduces the antimicrobial efficacy of any preservatives that may be present.57 The most frequently isolated mycobacteria include Mycobacterium chelonae, Mycobacterium haemophilum, Mycobacterium abscessus, Mycobacterium immunogenum, Mycobacterium massiliense, and Mycobacterium fortuitum.58 Clinically, papules, pustules, or ulcerated nodules limited to the tattooed area may be observed.59 In areas where leprosy is endemic, cutaneous inoculation with Mycobacterium leprae can occur, and manifestations may appear decades after the inoculation.60 In 2002, Ghorpade et al. described 31 cases of leprosy inoculated through tattoos and established the following diagnostic criteria: 1) Appearance of the first leprosy lesion after the tattoo, on the same site; 2) Presence of a single leprosy lesion on a single tattoo mark; 3) Histopathological evidence of leprosy and dermal tattoo pigment; 4) Absence of any pre-existing skin disease before the tattoo; 5) Demonstration of M. leprae in the tattoo instrument through smears or inoculation in the footpad of a mouse, if possible.60 Infections by Mycobacterium tuberculosis or Mycobacterium bovis have also been reported after tattooing, with clinical manifestations appearing 2- 4 weeks after inoculation. They are characterized by the formation of papules or erythematous nodules that progress to superficial ulcers (tuberculous chancre), accompanied by painless regional lymphadenopathy. In immunocompromised patients, progression to lupus vulgaris and tuberculosis cutis verrucosa, or even hematogenous dissemination, may occur.6,61 These infections should be considered when patients present with skin reactions decades after getting a tattoo or in patients who have been tattooed in prison or in environments where sterile techniques are not employed. Diagnostic tests include biopsy, tissue culture, and PCR for mycobacteria. Special stains for mycobacteria in biopsies are useful when positive but are not sufficient to rule out an infection. The tuberculin skin test also has great diagnostic value.16,27 Viral infections Some viral infections can be transmitted through contaminated instruments and inks used during tattooing. The most described ones include HIV, Hepatitis B (HBV), and Hepatitis C (HCV), although the risk of transmission under optimal biosafety conditions is very low.5,62 There have been reports of warts appearing at tattoo sites, with some cases being triggered by intense sunburn. It was postulated that local immunosuppression induced by UV radiation may reactivate the Human Papillomavirus (HPV). Therefore, a reasonable recommendation is to protect freshly tattooed skin from UV exposure.27,63 The most common serotypes of HPV are 3, 10, 27, 28, 47, and 49.23 Infection by the molluscum contagiosum virus may occur weeks or months after tattooing, and when it becomes widespread, it can happen in the context of an HIV infection.27 Herpes simplex virus type 1 can cause primary infection during the procedure or during the 497
D. Chalarca-Can˜as, M.A. Caviedes-Cleves, L.A. Correa-London˜o et al. Figure 7 Dermatofibroma. Dermis with non-encapsulated neoplasm of spindle cells with mild cytological atypia, surrounded by black ink pigment. The epidermis shows pseudoepitheliomatous hyperplasia, (Hematoxylin & eosin, [A] ×40, [B] ×100). Photographic archive of the Dermatopathology Laboratory, Dermatology Section, University of Antioquia. healing phase. In patients with a history of HSV-1 infection, it can reactivate, known as ‘‘herpes compunctorum’’. 64 Other viral infections possibly related to tattooing are molluscum contagiosum, rubella, and vaccinia. It should be noted that several of these infectious conditions are declining due to vaccination practices in early life stages and the increased use of aseptic techniques that mitigate the risk of viral transmission. 5,65 Fungal infections Cutaneous fungal infections in tattooed areas are very rare, although some cases of ringworm, pityriasis versicolor, candidiasis, sporotrichosis, aspergillosis, zygomycosis, or Acremonium infections have been described.27,59 Superficial mycoses can occur during the tattoo healing process, with the main etiological agent being Microsporum canis, a dermatophyte isolated from the hair of domestic animals.23 Parasitic infection These are extremely rare. Some cases of cutaneous leishmaniasis have been reported after tattoos in individuals with visceral leishmaniasis or HIV.27 Neoplastic complications Some cutaneous neoplasms have been described in association with tattooing, although there is limited epidemiological data to support this causal relationship. Benign neoplasms that have been reported include dermatofibromas (Fig. 7), seborrheic keratosis, epidermal cysts, miliaria, and pseudoepitheliomatous hyperplasia. However, it is believed that these neoplasms are underreported as they are rarely published.49,66 Other neoplasms more frequently reported include melanoma,67 basal cell carcinoma,68 squamous cell carcinoma,69 and keratoacanthoma.70,71 Rare cases of dermatofibrosarcoma protuberans, cutaneous leiomyosarcoma, and cutaneous lymphoma have also been reported.72 Melanoma and basal cell carcinomas have been primarily reported in black, dark blue, or other dark-colored tattoos, while squamous cell carcinomas, keratoacanthomas, and pseudoepitheliomatous hyperplasia have been more frequently associated with red tattoos.72 The pathogenesis could be multifactorial, given the presence of carcinogenic substances in tattoo ink such as aromatic amines and polycyclic aromatic hydrocarbons;14 the trauma induced by the tattooing procedure; chronic inflammatory response to foreign material in the skin; UV radiation; and genetic predisposition. Additionally, laser tattoo removal to break down the pigment into smaller segments could release even more carcinogens that may be present in the host’s reticuloendothelial system. Furthermore, it is believed that when a tattoo is applied over a nevus, the trauma and carcinogenic substances could induce dysplasia.72 While these findings may be coincidental, some case series have demonstrated the occurrence of neoplasms in tattoos at a younger age compared to epidemiological data in the general population, warranting further studies to establish this association.71,73 However, it is advisable for patients with melanocytic lesions or risk factors for melanoma to refrain from tattooing over pigmented lesions, and it would be ideal for tattoo artists to be aware of these complications. Cosmetic complications Dissatisfaction with the tattoo is the most common cosmetic complication, as it can distort the appearance of normal skin. Injecting pigment too deeply into the subcutaneous fat can cause pigment migration into the surrounding skin outside the edges of the original tattoo, resulting in distorted contours or a ‘‘blow-out’’ phenomenon, which can occur immediately after the completion of the tattoo.74,75 Since a tattoo is considered a massive trauma to the skin, 498
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