Dermatology: Practical and Conceptual Letter to Editor | Dermatol Pract Concept. 2025;15(4):5890 1 Melanomas Arising On Tattoos: The “Disruption Sign” Sabina Vaccari1, Raffaele Cirella1,2, Martina Lambertini 3, Marco Morante1,2, Beatrice Raone3, Emi Dika 1,2 1 Oncologic Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy 2 Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy 3 Dermatology Unit, Azienda Usl, Bellaria Hospital, Bologna, Italy Key words: Melanoma, Tattoo, Dermoscopy Citation: Vaccari S, Cirella R, Lambertini M, Morante M, Raone B, Dika E. Melanomas Arising On Tattoos: The “Disruption Sign”. Dermatol Pract Concept. 2025;15(4):5890. DOI: https://doi.org/10.5826/dpc.1504a5890 Accepted: April 22, 2025; Published: October 2025 Copyright: ©2025 Vaccari 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.s Authorship: All authors have contributed significantly to this publication. Corresponding Author: Vaccari Sabina, Oncologic Dermatology Unit, IRCCS di Policlinico Sant’Orsola, via Massarenti 9, 40138, Bologna, Italia. ORCID ID: 0000-0001-9102-2843. E-mail: sabina.vaccari@aosp.bo.it To the Editor, Tattoos may be related to a number of dermatological com- plications: cutaneous neoplasms, particularly melanomas (cMs), have been reported, but the pathogenesis remains con- troversial [1-4]. Forty-three cMs on tattoos (cMT) have been reported, occurring more frequently in males and younger patients, with a higher mean Breslow thickness, possibly re- lated to a delayed diagnosis [5,6]. No case series of cMT dermoscopic features have been reported and we report four cases (Table 1, Figures 1 and 2). The most common dermoscopic feature was the atypical reticular pattern (4/4, 100%), followed by grayish-blue areas (3/4, 75%) and homogeneous areas (2/4, 50%). Cobblestone pattern, blue-gray veil, gray circles, regression structures, dots/globules, and peppering were observed in 1/4 cMTs. Grayish-blue areas were likely related to the black ink as they were not present in the cMT arising on the yellow tattoo. All the cMTs were atypical clinical lesions, representing clinical “ugly ducklings,” but they had not been noticed by the patients. The atypical clinical features according to the ABCDE rule were a hint of the malignant nature and even more worrisome than the dermoscopic elements. Indeed, tat- toos represent an obstacle to self- and medical clinical exam- ination as well as to dermoscopic assessment. The presence of superimposed ink can mimic a blue-gray veil and mask the vascular pattern and the borders. As shown in Cases 1 and 2, at low magnification, the ink can create two different der- moscopic areas with a prominent diversity (Figures 1B–D). The harmonic features and image of the tattoos had been altered by the cMT (“disruption sign”), representing a clue of the subsequent origin of the lesion. Indeed, usually 2 Letter to Editor | Dermatol Pract Concept. 2025;15(4):5890 Table 1. Clinical and Dermoscopic Features of the Reported Cases. Case 1 F 50 Arm Melanoma in situ Homogeneous areas Cobblestone Atypical reticular Gray circles Grayish-blue areas Case 2 F 41 Dorsum Melanoma, pT1a, Breslow 0.3 mm Grayish-blue areas Atypical reticular Homogeneous areas Dots/globules Case 3 M 48 Dorsum Melanoma, pT1a, Breslow 0.5 mm Atypical reticular Peppering Blue-gray veil Regression structures Case 4 M 46 Torax Melanoma, pT1a, Breslow 0.5 mm Grayish-blue areas Atypical reticular Figure 1. Clinical (A,C, red arrows) and dermoscopic (B,D) features of the excised mel- anomas on tattoos. a professional tattoo is performed around a pre-existing nevus, sparing its borders and aesthetic appearance (Figure 2A, blue arrows). The drawing itself can help the clinician to monitor the evolution of the pigmented lesion at sequential images, representing points of reference. In those tattoos with complex drawings and multiple nevi or photodamage (Figures 2A), cMT may be misjudged as part of the tattoo itself. Our goal is to raise awareness of cMT and emphasize the importance of a thorough clinical and dermoscopic exam- ination. Further studies and the new available technologies are required to elucidate cMT diagnostic features in order to avoid unnecessary excisions with a heavy cosmetic impact. CMs may alter the harmony of the colour and shape of the pre-existing tattoo (“disruption sign”) and represent a clini- cal “ugly duckling.”  Letter to Editor | Dermatol Pract Concept. 2025;15(4):5890 3 References 1. Ricci F, Paradisi A, Maier SA, et al. Melanoma and tat- toos: a case report and review of the literature. Eur J Der- matol .2018;28(1):50-55.DOI:10.1684/ejd.2017.3184. PMID: 29171408s 2. Wenzel SM, Rittmann I, Landthaler M, Bäumler W. Adverse Re- actions after Tattooing: Review of the Literature and Compari- son to Results of a Survey. Dermatology. 2013;226(2):138-147. DOI:10.1159/000346943. PMID: 23689478 3. Scarfì F, Patrizi A, Veronesi G, et al. 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