Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2022;12(3):e2022121 1 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 Delayed cutaneous tattoo reactions are a relatively rare oc- currence and include, lichenoid, granulomatous, allergic, pseudoepitheliomatous (PEH), and pseudolymphoma. Der- moscopic features of delayed tattoo reaction patterns are rarely reported [1]. Case presentation A 21-year-old male had a one-year history of a slow-grow- ing, asymptomatic lesion over a blue tattoo. It started six months after the tattooing. Cutaneous examination showed solitary erythematous to bluish verrucous plaque over the tattoo (Figure 1A). Dermoscopic examination under non- polarized mode revealed two distinct zones. The central area had white scales, white to pinkish-white structure- less area, comedo-like opening with keratotic plugging, white circles, red globules, hemorrhage, hairpin, and linear irregular vessels. The peripheral zone showed a gray-white to bluish-white structureless area (Figure 1, B and C). The differential diagnoses included were lupus vulgaris, tuber- culosis verrucosa cutis (TBVC), chromoblastomycosis, and granulomatous tattoo reaction pattern. Histology showed hyperkeratosis, parakeratosis, pseudoepitheliomatous hyperplasia, spongiosis, and lymphocytic exocytosis. In addition to tattoo pigment, the dermis had a subepider- mal band-like, perivascular and peri-adnexal predominant lymphocytic infiltration and occasional plasma cells. Also, the epidermis showed focal keratinocyte swelling, dysker- atotic cells, and the dermis showed an increased number and dilated dermal blood vessels. (Figure 2, A and B). Other investigations were within normal limits. The diagnosis of PEH tattoo reaction pattern was made, and the patient was treated with intralesional triamcinolone acetonide 40 mg/ml. PEH is the result of benign hyperplasia of the epider- mal and adnexal epithelium. Tattoo-induced PEH is a rare 2 Research Letter | Dermatol Pract Concept. 2022;12(3):e2022121 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). (C) The peripheral zone shows a gray-white to bluish-white struc- tureless area and hairpin vessels (blue arrow). Red arrow points white circle. Figure 2. (A) Histology shows pseudoepitheliomatous epidermal hyperplasia (H & E, X100). (B) A subepidermal band-like, perivas- cular and periadnexal, predominant lymphocytic infiltration, along with tattoo pigments (H&E, X100). benign reaction pattern commonly to red or purple pig- ment. Differentiating PEH from squamous cell carcinoma (SCC) is vital to reduce patient morbidity and cosmetic disfigurement, as the latter can occur independently over tattoo or arise from the PEH. The early onset and lesions confinement to the tattoo margins favors PEH, while a late onset and involvement beyond the tattoo border sug- gest SCC. Research Letter | Dermatol Pract Concept. 2022;12(3):e2022121 3 A homogenous violaceous pattern with follicular white-yellow halo was reported in a case of tattoo pseudo- lymphoma [1]. The dermoscopic features described for SCC are scales, keratin, white circles around a dilated and plugged follicular infundibulum, white structureless area, blood spots, and hairpin, linear, linear irregular, glomerular, or polymorphic vascular pattern [2]. In the index case, the following dermoscopic features overlapped with SCC: white homogenous area, keratotic follicular plugging surrounded by white circles, and polymorphous vascular structures. However, the patient age, temporal correlation, and circum- scription of the plaque, along with dermoscopic findings, were suggestive of PEH. The dermoscopic features described for other differen- tial diagnoses are the following: lupus vulgaris shows a dif- fuse or localized yellow-orange structureless area and linear branching vessels; TBVC displays a yellowish-red to yellowish- brown areas, scales, and out-of-focus vascular structures; chromoblastomycosis is reported to have scale, crust, and yellow structureless and pink-white areas; and granuloma- tous tattoo reaction shows crystalline structures and orange structureless area [3-5]. Conclusions We are reporting the clinico-dermoscopic-pathologic fea- tures of a case of PEH tattoo reaction pattern. Dermoscopy may help distinguish PEH from other differential diagnoses described above, but not from SCC, in which case only clin- ical and anamnestic data may help in their differentiation. References 1. Kendel M, Toncic RJ, Bradamante M, et al. Dermoscopy of a tattoo pseudolymphoma. Dermatol Pract Concept. 2019;9(1): 17-19. DOI: 10.5826/dpc.0901a04. 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