Dermatology: Practical and Conceptual


Image Letter | Dermatol Pract Concept. 2024;14(1):e2024011 1

“A Strange Flower in the Garden”: The Importance 
of the Dermatoscope in the Assessment of Tattoos
Júlia Verdaguer-Faja1, Verónica Mora-Fernandez1, Maria Fabregat-Pratdepadua1, Ane Jaka1

1 Dermatology and Venereology Department. Germans Trias i Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Spain

Citation: Verdaguer-Faja J, Mora-Fernandez V, Fabregat-Pratdepadua M, Jaka A. “A Strange Flower in the Garden”: The Importance of the 
Dermatoscope in the Assessment of Tattoos. Dermatol Pract Concept. 2024;14(1):e2024011. DOI: https://doi.org/10.5826/dpc.1401a11

Accepted: September 5, 2023; Published: January 2024

Copyright: ©2024 Verdaguer-Faja et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial 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: Júlia Verdaguer-Faja, Dermatology Department. Hospital Universitari Germans Trias I Pujol. Carretera de Canyet 
s/n. 08916, Badalona (Barcelona), Spain. Phone: 0034934978813 E-mail: verdaguer.ju@gmail.com

Case Presentation

A 49-year-old healthy female presented with a 12-months 

history of an asymptomatic red and crusty lesion on her 

left arm, next to a tattoo inoculated 6 years before. Cuta-

neous examination showed a red plaque with yellow crust 

and erosions, next to the black and red tattoo (Figure 1A). 

Under the diagnostic suspicion of infectious impetigo vs. 

reactive dermatosis to tattoo ink, treatment with topical 

corticosteroids and antibiotics was prescribed, showing 

only partial improvement and persistence of the plaque at 

the two-month follow-up (Figure 1B). This time, the use of 

dermoscopy revealed small erosions, arborizing telangiecta-

sias (white arrows) and concentric structures (green arrows) 

(Figure 1C), suggesting the diagnosis of superficial basal cell 

carcinoma associated to tattoo, what was later confirmed by 

a skin biopsy.

Teaching Point

Decorative tattooing involves the introduction of exogenous 

pigments into the dermis. Complications include primarily 

infections, allergy to tattoo pigments, the localization of 

 various dermatoses to tattoos, but also benign and some-

times malignant tumors arising on them [1,2], such as mela-

noma or basal cell carcinoma. The occurrence of cutaneous 

malignancies in tattoos may be related to the “scarring pro-

cess” and local chronic inflammation, and the presence of 

carcinogenic substances in tattoo ink. However, a directly 

causative relationship cannot yet be confirmed [1,2].

Although pigment allergy is the most common tattoo 

complication, especially when red ink is used [1], we claim 

the importance of using dermoscopy in the assessment of 

any lesion in a tattoo, as malignant tumors may also arise 

on them. In addition, it can also facilitate the diagnosis of 



2 Image Letter | Dermatol Pract Concept. 2024;14(1):e2024011

tattoo infectious complications like viral warts, molluscum 

contagiousum or demodicosis, and, consequently, reduce the 

number of unnecessary biopsies [3]. 

 References 

1.   Kluger N. An update on cutaneous complications of permanent 

tattooing.  Expert Rev Clin Immunol.  2019;15(11):1135-1143. 

DOI: 10.1080/1744666X.2020.1676732. PMID: 31594417.  

2.   Leijs M, Schaefer H, Rübben A, Cacchi C, Rustemeyer T, 

van der Bent S. Cutaneous malignancies in tattoos, a case series of 

six patients.  Curr Oncol.  2021;28(6):4721–3477. DOI: 10.3390

/curroncol28060398. PMID: 34898571. PMCID: PMC8628776.  

3.   Rogowska P, Sobjanek M, Sławińska M, Nowicki RJ, 

 Szczerkowska-Dobosz A. Tattoos Dermatological Complica-

tions: Analysis of 53 Cases from Northern Poland.  Dermatol-

ogy.  2022;238(4):799-806. DOI: 10.1159/000520752. PMID: 

34969030.  

     Figure       1   .  (A) Cutaneous examination showed a red plaque with yellow crust and erosions, next to one of 

the tattoo red flower and black branch (tattoo of a tree in bloom with black and red colors). (B) Persistence 

of a red plaque, although with less crust and erosions. (C)   Examination of the red plaque with dermos-

copy revealed the presence of small erosions (black arrows), arborizing telangiectasias (white arrows) and 

 concentric structures (green arrows).