Pathogenesis, Diagnosis and Management of Squamous Cell Carcinoma and Pseudoepithelial Hyperplasia Secondary to Red Ink Tattoo: A Case Series and Review

Abstract

The increasing popularity of tattooing has paralleled an increase in associated cutaneous reactions. Red ink is notorious for eliciting cutaneous reactions. A common reaction is pseudoepitheliomatous hyperplasia (PEH), which is a benign condition closely simulating squamous cell carcinoma (SCC). Differentiating PEH from SCC is challenging for pathologists and clinicians alike. The exact pathogenesis of these lesions secondary to red ink is not known, and there are no sources outlining diagnostic and treatment options and their efficacy. We present four study cases with different pathologies associated to red ink tattoos including lichenoid reaction, granulomatous reaction, PEH, and an SCC. Additionally, an extensive review of 63 articles was performed to investigate pathogenesis, diagnostic approaches, and treatment options. Hypotheses surrounding pathogenesis include but are not limited to the carcinogenic components of pigments, their reaction with UV and the traumatic process of tattooing. Pathogenesis seems to be multifactorial. Full-thickness biopsies with follow-up is the recommended diagnostic approach. There is no evidence of a single universally successful treatment for PEH. Low-dose steroids are usually tried following a step up in lack of clinical response. For SCC lesions, full surgical excision is widely used. A focus on clinicians' awareness of adverse reactions is key for prevention. Regulation of the unmonitored tattoo industry remains an ongoing problem.

Keywords: diagnosis; pseudoepitheliomatous hyperplasia; red; squamous cell carcinoma; tattooing; treatment.

Figure 1

Photograph taken immediately after tattoo was imprinted (a). Photograph taken six months after receiving the tattoo. Note the scaly, raised exophytic lesion in areas tattooed with red ink only while the black ink areas remain spared (b).

Figure 2

Skin biopsy at 12.5× magnification (a) showing orthokeratosis, hyperplastic squamous epithelium, papillomatous change and lichenoid inflammation at superficial dermis. At 100× magnification (b), tattoo pigment and lichenoid reaction is shown in the superficial dermis.

Figure 3

Eighteen months follow up with significant clinical improvement after management with six sessions of intra-lesional steroid injections and topical corticosteroid. The tattoo is no longer raised, scaly or pruritic. The tattoo is largely preserved with an acceptable aesthetic outcome.

Figure 4

Skin lesion affecting exclusively red-ink tattooed areas 6 months after initial tattoo was completed (a). Macroscopic appearance after deep shave biopsy was performed (b).

Figure 5

Histopathological photograph at 40× magnification (a) and 100× magnification (b) showing the features of the pseudoepitheliomatous hyperplasia (PEH) with haematoxylin eosin stain (H&E).

Figure 6

Macroscopic appearance after deep shave biopsy was performed.

Figure 7

Histological features of necrotising granulomatous reaction. Note the necrosis in the dermis, surrounding giant cells and some pigment. (a) low power; (b) high power.

Figure 8

Clinical photograph of two scaly lesions of the skin located in the red-inked areas of a multi-coloured tattoo of the left arm completed 13 years earlier.