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Table of Contents
CORRESPONDENCE
Year : 2021  |  Volume : 39  |  Issue : 2  |  Page : 95-96

A case of tattoo-related basal cell carcinoma in Taiwan


Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

Date of Submission14-Sep-2020
Date of Decision24-Oct-2020
Date of Acceptance16-Nov-2020
Date of Web Publication23-Jun-2021

Correspondence Address:
Dr. Yu-Ju Tseng
Department of Dermatology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, No. 123, Ta-Pei Road, Niao-Sung District, Kaohsiung 83301
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ds.ds_54_20

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How to cite this article:
Cheng AY, Tseng YJ. A case of tattoo-related basal cell carcinoma in Taiwan. Dermatol Sin 2021;39:95-6

How to cite this URL:
Cheng AY, Tseng YJ. A case of tattoo-related basal cell carcinoma in Taiwan. Dermatol Sin [serial online] 2021 [cited 2021 Jul 25];39:95-6. Available from: https://www.dermsinica.org/text.asp?2021/39/2/95/319152



Dear Editor,

Skin cancers arising from tattoo are rare. There have been only a few case reports, despite increasing number of tattooed individuals.[1] We report the first case of tattoo-related basal cell carcinoma (BCC) in Taiwan.

A 41-year-old Taiwanese woman has hepatitis C with regular medical follow-ups. There was one asymptomatic, irregular-shaped, blackish enlarging nodule developing on her back. The nodule arose from one large dark blue to black-colored tattoo, which was placed 25 years ago. She received laser therapy for tattoo removal in a beauty clinic [Figure 1]a and [Figure 1]b. The information of the progression, shape, and color change of the tumor was not available due to the lack of self-awareness. She denied frequent sun exposure, prior trauma history, and she also denied constitutional symptoms. Physical examination showed one 1.8 cm× 2.2 cm blackish irregular nodule with elevated border emerging from the blackish tattoo occupying her upper back [Figure 1]a and [Figure 1]b. There was no palpable lymphadenopathy. Dermoscopy showed blackish globules and focal ulcers. Histopathological findings from skin biopsy revealed the buds of basophilic tumor cells with peripheral palisading, and they extend into the dermis from the basal layer of the epidermis [Figure 1c]. The final diagnosis was superficial BCC arising from prior tattoo. After the confirmation of BCC, she received wide excision of the BCC with a free margin of 3 mm and reconstruction with bilateral advanced V-Y flaps [Figure 2]a and [Figure 2]b. Complete tumor removal with clear margin was achieved. We had a subsequent follow-up for the patient 8 months later, and there were no signs of recurrence until the completion of this article [Figure 2]c and [Figure 2]d.
Figure 1: The clinical and histologic pictures. (a) One tumor on the tattooed back of the 41-year-old female patient. (b) One brownish to blackish irregular plaque on the blackish tattoo. (c) Buds of basophilic tumor cells characterized by peripheral palisading extend into the dermis from the basal layer of the epidermis (H and E, ×100).

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Figure 2: (a) The design of wide excision of basal cell carcinoma and the reconstruction with bilateral advanced V-Y flap (b) Postoperation picture (c) Follow-up at 2 weeks (d) Follow-up at 3 months.

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Tattoo is permanent body decoration using exogenous pigments and dyes penetrating deep into the dermis. The prevalence of tattoo increased in the past decades in the Western countries, estimated to be 10%–20%.[2] The tattoo prevalence of adolescents in Southern Taiwan was 1%, which is much lower than Western countries.[3] Well-known complications of tattoo include allergic and foreign-body reaction, infection, scar and keloid formation, tumors, miscellaneous cutaneous complications, and psychosocial complications.[4] In the context of tumor, benign tumors including seborrheic keratosis, histiocytofibroma, epidermal cyst, and milia are well-understood, whereas tattoo-related skin cancers are relatively rare. After reviewing literatures, the tattoo-associated skin cancers comprise squamous cell carcinoma, melanomas, BCCs, and other rare cutaneous malignancies (e.g., dermatofibrosarcoma protuberans, leiomyosarcoma, and B-cell lymphoma). To date, only 14 cases of tattoo-related BCC have been reported (including current case).[1]

BCC is the most common skin cancer with a higher prevalence in the elder population, and it mostly develop on the sun-exposed areas. Comparing to conventional BCC, tattoo-related BCC tends to develop in younger patients and with no relevance to UV exposure, as shown in our case. Although the association between tattoo and skin cancer was yet to be determined, some literature proposed that the BCC growing on the tattoo was more than coincidental findings.[1],[5] Carcinogenesis of BCC arising from tattoo has been proposed to be multifactorial, which may include the genetic predisposition, trauma induced by insertion of exogenous materials, chronic inflammation, the immunocompromised district of the skin –inherited or acquired vulnerable skin areas comparing to the rest of the body due to UV or ionizing radiation, herpes infection, or trauma.[1],[6],[7] The most widely discussed hypothesis was the insertion of potential carcinogens. The tattoo ingredients, including metallic salts, organic dyes, and other auxiliary ingredients, as well as its byproducts after sun exposure, laser, or physiological metabolism are mostly poorly understood, and some are regarded as toxic, carcinogenic, or potentially carcinogenic.[6] Recently, one population-based case–control study showed the increased risk of early onset BCC at the tattoo site compared to the nontattoo site and stronger association between green and yellow tattoo and BCC at the tattoo site.[8] However, the relation between the color of tattoo and carcinogenesis of skin cancers remains uncertain.

Although there is no gold standard management of tattoo-related BCC, surgical removal of the tumor with clear margin remains the most effective treatment. In our case, based on histologically noninfiltrative type, we performed wide excision with V-Y flap reconstruction with clear margin. Regular follow-ups revealed no recurrence 8 months after the surgery.

In conclusion, we presented the first case of BCC arising from tattoo in Taiwan. The risks of tattoo, especially the possibility of developing skin cancer, should be alarmed to the public. Further investigations are required to clarify the causality and the pathogenesis of tattoo-related BCC.


  Ethical approval Top


This study is approved by the Institutional Review Board of Chang Gung Medical Foundation (approval number: 202001494B0). Patient informed consent was waived by the IRB.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abudu B, Erickson CP, Calame A, Cohen PR. Basal cell carcinoma originating in a tattoo: Case report and review of an uncommon complication in tattoo recipients. Dermatol Pract Concept 2019;9:265-70.  Back to cited text no. 1
    
2.
Kluger N. Epidemiology of tattoos in industrialized countries. Curr Probl Dermatol 2015;48:6-20.  Back to cited text no. 2
    
3.
Yen CF, Hsiao RC, Yen JY, Yeh YC, Wang PW, Lin HC, et al. Tattooing among high school students in Southern Taiwan: The prevalence, correlates and associations with risk-taking behaviors and depression. Kaohsiung J Med Sci 2012;28:383-9.  Back to cited text no. 3
    
4.
Khunger N, Molpariya A, Khunger A. Complications of tattoos and tattoo removal: stop and think before you ink. J Cutan Aesthet Surg 2015;8:30-6.  Back to cited text no. 4
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5.
Engel E, Ulrich H, Vasold R, König B, Landthaler M, Süttinger R, et al. Azo pigments and a basal cell carcinoma at the thumb. Dermatology 2008;216:76-80.  Back to cited text no. 5
    
6.
Kluger N, Koljonen V. Tattoos, inks, and cancer. Lancet Oncol 2012;13:e161-8.  Back to cited text no. 6
    
7.
Ruocco V, Brunetti G, Puca RV, Ruocco E. The immunocompromised district: A unifying concept for lymphoedematous, herpes-infected and otherwise damaged sites. J Eur Acad Dermatol Venereol 2009;23:1364-73.  Back to cited text no. 7
    
8.
Barton DT, Zens MS, Marmarelis EL, Gilbert-Diamond D, Karagas MR. Cosmetic tattooing and early onset basal cell carcinoma: A population-based case-control study from New Hampshire. Epidemiology 2020;31:448-50.  Back to cited text no. 8
    


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