Dermatopathology
In vivo and ex vivo dermoscopy of lesions from implantation of human papillomavirus in tattoos: report of two cases
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Erythroderma and fatal outcome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "75" "paginaFinal" => "77" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 639 "Ancho" => 855 "Tamanyo" => 107622 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diffuse erythema, vesicular lesions, erosions, and crusts in lower limbs close to inguinal folds.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Paula Baldissera Tansini, Ana Letícia Boff, Magda Blessmann Weber, Renan Rangel Bonamigo" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Paula Baldissera" "apellidos" => "Tansini" ] 1 => array:2 [ "nombre" => "Ana Letícia" "apellidos" => "Boff" ] 2 => array:2 [ "nombre" => "Magda Blessmann" "apellidos" => "Weber" ] 3 => array:2 [ "nombre" => "Renan Rangel" "apellidos" => "Bonamigo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2666275219300840" "doi" => "10.1016/j.abdp.2019.02.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275219300840?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059619301497?idApp=UINPBA00008Z" "url" => "/03650596/0000009500000001/v3_202003240622/S0365059619301497/v3_202003240622/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Dermatopathology</span>" "titulo" => "<span class="elsevierStyleItalic">In vivo</span> and <span class="elsevierStyleItalic">ex vivo</span> dermoscopy of lesions from implantation of human papillomavirus in tattoos: report of two cases" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "78" "paginaFinal" => "81" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "John Verrinder Veasey, Ana Luisa Nasser Erthal, Rute Facchini Lellis" "autores" => array:3 [ 0 => array:4 [ "nombre" => "John Verrinder" "apellidos" => "Veasey" "email" => array:1 [ 0 => "johnveasey@uol.com.br" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ana Luisa Nasser" "apellidos" => "Erthal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Rute Facchini" "apellidos" => "Lellis" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Dermatology Clinic, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Pathology Laboratory, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 637 "Ancho" => 1500 "Tamanyo" => 145332 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Clinical aspect of the tattoo with multiple papules arranged linearly. (B) <span class="elsevierStyleItalic">In vivo</span> dermoscopy (×10 magnification) showing papules with digitiform and red dotted projections corresponding to vascular ectasias. (C) <span class="elsevierStyleItalic">Ex vivo</span> dermoscopy (×20 magnification) showing papillomatous and dotted hemorrhagic projections in the epidermis, with presence of pigment in the superficial dermis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The practice of skin ornamentation is a habit as old as human civilization, having been found in mummies from the period between 2000 and 4000 BC.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Currently, it is estimated that 21% of the adult population of the United States has at least one tattoo,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> and 25% in Germany.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Regarding the Brazilian population, the prevalence of individuals with a tattoo varies from 10% to 26% in men and from 10% to 22% in women.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">During the tattooing process, the individual is exposed to histological reactions to the pigments (eczematous, sarcoid, granulomatous, pseudolymphomatous),<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> as well as infections caused by different pathogens, which can lead to severe sequelae and difficult treatment.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> Among these infections, there are reports of systemic diseases such as hepatitis B, hepatitis C, and HIV infection,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> and those restricted to the skin, such as atypical mycobacterioses<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,5</span></a> and warts.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This report presents two cases of patients who, after receiving a tattoo, developed lesions on the pigmentation line, having a clinical, dermatoscopic, and histopathological diagnosis of wart.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the first case, a 39-year-old man with a tattoo on the left side of the left calf for eight years reported localized lesions on the tattoo for seven years. He denied continued use of medications or use of topical medications on the lesions. At the examination, there were numerous erythematous scaling papules that varied between 3 and 7<span class="elsevierStyleHsp" style=""></span>mm in diameter, arranged on the contours of the tattoo, forming linear paths. At dermoscopy, some projections of similar diameter and length were observed in a “knob” pattern over the papules, with thrombosed glomerular capillaries, giving the appearance of red spots on the lesion's surface. An incisional biopsy with punch was performed and an <span class="elsevierStyleItalic">ex vivo</span> dermoscopy was performed for a better analysis of the cutaneous structures and their alterations. A papillomatous verruciform appearance in the epidermis was presented, with underlying pigment in the dermis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The result of histopathological examination was compatible to a wart over a tattoo (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In the second case, a 33-year-old man with a tattoo on the left upper limb for 12 years reported lesions that disseminated six years previously on the design of his tattoo. He was positive for HIV infection, using zidovudine, lamivudine, ritonavir, and darunavir (viral load undetectable and CD4+ cells count: 582/mm<span class="elsevierStyleSup">3</span>) and genital condylomata acuminate (multiple papillomatous warts), under treatment. Physical examination showed a dermatosis located on the left arm characterized by multiple flattened erythematous and confluent papules, forming plaques with defined and irregular borders. Some lesions accompanied the tattoo design, while others affected healthy skin. Dermoscopy presented a nonspecific appearance, with isolated spots of desquamation. An incisional biopsy was performed, and as in the first case, an <span class="elsevierStyleItalic">ex vivo</span> dermoscopy of was performed, showing a slightly thickened epidermis with discrete papillomatosis and presence of pigment in the dermis (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The result of the histopathological examination confirmed the diagnosis of a wart over a tattoo (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Reports of skin contamination from the tattooing process have increased in recent years, from infectious bacterial diseases such as atypical mycobacterioses and leprosy, to viral infections such as warts and molluscum contagiosum, and to diseases transmitted by sexually transmitted infection such as syphilis. Such an increase has stimulated a joint action of the United States Food and Drug Administration with the Centers for Disease Control and Prevention to revise the health surveillance criteria for tattoo centers. Another important step was the education of health professionals for the recognition and appropriate treatment of infections and cutaneous reactions in tattoos.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Warts are frequent skin conditions caused by the human papillomavirus (HPV), a DNA virus of universal distribution.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Dysfunction in the epithelial barrier due to trauma causes microscopic disruptions in the skin, allowing viral transmission. In the cases presented, there was damage to the skin barrier during tattooing, with possible inoculation of the virus during the process.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Viral warts in the affected area may arise after an incubation period that generally ranges from three weeks to eight months.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> In some cases, the latency period is longer, and may reach ten years, making it difficult to relate the onset of the lesion to direct inoculation through the procedure. In these cases, it is proposed that the development of warts would depend on dysregulation of the immune system,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> since cell-mediated immunity plays an important role in the host's response to HPV.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> This can be evidenced in the second patient with HIV, who presented more extensive and persistent lesions.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In a review of wart implantation on tattoos, it was observed that the risk of acquiring a wart on black pigment is seven-fold greater than on colored pigment or on non-tattooed skin.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> In the first case here reported, the patient had no comorbidities and presented warts restricted to the tattoo, while the second patient presented lesions that did not respect the pigment linearity, including healthy skin.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Dermoscopy was of great value in the reported cases. Aspects classically present in common and anogenital warts were observed in the lesions on the tattoos presented here in the first case,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a> making possible the diagnosis of the HPV-induced lesion, even over the pigment. In the second case, it was harder to identify such dermatoscopic features, which were also rare in the clinical presentation. Sequencing for HPV in this case would be very worthwhile to better characterize if the lesion is a beta-papillomavirus, and whether the HPV of the condyloma acuminata is the same as that of the tattoo. However, it was not possible to carry out such analysis.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Another illustrative aspect of this study is the <span class="elsevierStyleItalic">ex vivo</span> dermatoscopy, where it was possible to identify both the epidermal alterations caused by HPV and the dermal changes produced by the presence of tattoo pigment. These findings were compatible with those identified in the histopathological examination.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The importance of the present study is its description of the clinical, dermoscopic, and histological aspects of HPV infection associated with tattoos, as well as the findings of <span class="elsevierStyleItalic">ex vivo</span> dermatoscopy similar to those identified in the histopathological examination. The authors emphasize the importance of the clinical suspicion of HPV infection, manifested by the appearance of warts after tattooing, and the need to adopt public health measures that make this procedure safer, in order to avoid future events.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Financial support</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Authors’ contribution</span><p id="par0060" class="elsevierStylePara elsevierViewall">John Verrinder Veasey: Approval of the final version of the manuscript; conception and planning of the study; elaboration and writing of the manuscript; obtaining, analyzing, and interpreting the data; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of the cases studied; critical review of the literature; critical review of the manuscript.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Ana Luisa Nasser Erthal: Conception and planning of the study; elaboration and writing of the manuscript; obtaining, analyzing, and interpreting the data; critical review of the literature; critical review of the manuscript.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Rute Facchini Lellis: Obtaining, analyzing, and interpreting the data; intellectual participation in propaedeutic and/or therapeutic conduct of the cases studied.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:3 [ "identificador" => "xres1321064" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1218659" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0010" "titulo" => "Financial support" ] 3 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ contribution" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-11-06" "fechaAceptado" => "2019-02-12" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1218659" "palabras" => array:5 [ 0 => "Dermoscopy" 1 => "Histology" 2 => "Comparative" 3 => "Tattooing" 4 => "Warts" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The number of individuals with tattoos has been increasing worldwide, alongside with reports of complications varying from reactions to the injected pigments to infections caused by agents inoculated in the pigmentation process. The diagnosis of such unwanted events can be obtained through complementary non-invasive methods, preserving the maximum of the tattoo design. The authors present two cases of patients with warts on tattooing, and correlate their clinical aspects to <span class="elsevierStyleItalic">in vivo</span> and <span class="elsevierStyleItalic">ex vivo</span> dermoscopy, and to the findings in the histopathological examination, aiming to determine patterns that aid the diagnosis of these lesions without performing biopsy.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Veasey JV, Erthal AL, Lellis RF. <span class="elsevierStyleItalic">In vivo</span> and <span class="elsevierStyleItalic">ex vivo</span> dermoscopy of lesions from implantation of human papillomavirus in tattoos: report of two cases. An Bras Dermatol. 2020;95:78–81.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Dermatology Clinic, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 637 "Ancho" => 1500 "Tamanyo" => 145332 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Clinical aspect of the tattoo with multiple papules arranged linearly. (B) <span class="elsevierStyleItalic">In vivo</span> dermoscopy (×10 magnification) showing papules with digitiform and red dotted projections corresponding to vascular ectasias. (C) <span class="elsevierStyleItalic">Ex vivo</span> dermoscopy (×20 magnification) showing papillomatous and dotted hemorrhagic projections in the epidermis, with presence of pigment in the superficial dermis.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 837 "Ancho" => 1500 "Tamanyo" => 259972 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histopathological exam of patient 1, stained with hematoxylin & eosin. (A) ×40 magnification, presenting epidermis with papillomatosis, prominent hyperkeratosis with parakeratosis, hypergranulosis, acanthosis and elongated epidermal ridges, and dermis with presence of extracellular deposits of black pigment, compatible with exogenous pigment. (B) ×200 magnification evidencing detail of papillomatosis. (C) ×200 magnification with detail of black pigment accumulation in dermis.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 657 "Ancho" => 1500 "Tamanyo" => 152316 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A) Clinical appearance of the tattoo, with multiple discrete and diffuse erythematous papules, both on the tattoo and on healthy skin. (B) <span class="elsevierStyleItalic">In vivo</span> dermoscopy (×10 magnification) showing details of the papules with unspecific desquamation, without digitiform projections and red dots. (C) <span class="elsevierStyleItalic">Ex vivo</span> dermoscopy (×20 magnification) showing a slightly thickened upper portion the epidermis with discrete flat papillomatous projections, associated with the presence of pigment in the superficial and medium dermis.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 721 "Ancho" => 1500 "Tamanyo" => 298151 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Histopathological exam of Patient 2, stained with hematoxylin & eosin. In (A) (×200 magnification) hyperkeratotic epidermis with the presence of balonized keratinocytes on the epidermal surface is observed. In the dermis, there are exogenous black pigment deposits around the vessels. In (B) (×400 magnification), nuclear polymorphism and hyperchromia are evident, in addition to the broad and basophilic cytoplasm of keratinocytes, characterizing the cytopathic effect of HPV. In (C) (×400 magnification), the black pigment of the tattoo deposited around the vessels is observed.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tattooing: profile and discourse of individuals with marks in the body" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.L.Z. Lise" 1 => "A. Cataldo Neto" 2 => "J.G.C. Gauer" 3 => "H.Z.J. Dias" 4 => "V.L. 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