DR [Dermatology Reports 2011; 3:e47] [page 105] Pseudolymphoma tattoo-induced Giorgio Pasolini,1 Patrizia Ghidini1, Mariachiara Arisi,1 Alessandra Pedretti,1 Marco Ungari2 Piergiacomo Calzavara Pinton1 1Department of Dermatology and 2Department of Pathology, Spedali Civili di Brescia, University of Brescia, Italy Abstract Tattooing has become more and more popu- lar in today’s society. The most common derma- tological tattoo complications are represented by hypersensitivity reaction to tattoo pigments like irritant and allergical contact dermatitis, development of lichenoid areas and granuloma- tous responses, such as sarcoid granulomas or foreign body granulomas. Less frequently patients developing discoid lupus erythema- tous have been reported. Pseudolymphoma is an uncommon reactive lymphocytic prolifera- tion mimicking the histological and clinical features of a malignant skin lymphoma. We herein report a pseuldoymphoma limited to the red area of a multicolour tattoo of the leg. Case Report A 34-year-old man presented with a six months history of mildly itching plaque of the left leg that he developed two months after the injection of a tattoo (Figure 1). The patient was otherwise in good health and he had no personal or family history of allergic diseases or contact dermatitis. At dermatological exam- ination, we observed a 12 square centimeters persistent swelling of the red area of a multi- colour (red, black, green, yellow and blue) tat- too of the left leg. There was no involvement of the regional lymphonodes. A 4 mm punch skin biopsy was performed and histopathological examination showed acanthosis, enlarged interpapillary ridges and compact ortho-hyper- keratosis overlying a dense dermal infiltrate of lymphocytes of small and moderate size with- out nuclear atypia, sometimes grouped in clus- ters and with exocitosis. Scattered macro- phages with small intracytoplasmic granules of brown pigment, fibrous reaction and focal ery- throcyte extravasations were seen as well (Figure 2). On immunohistochemical analysis the lymphoid infiltrate showed a CD3 + CD4 + phenotype, with scattered CD20 + B lymphoid cells (Figure 3). CD30 + large cells were not detected. The plasma cell population showed a polytypical pattern of immunoglobulin light- chains. The histological architectural pattern suggested a diagnosis of T-cell pseudolym- phoma. Patch tests with the Standard series recom- mended by the Italian Society of Occupational and Environmental Allergological Dermatology (SIDAPA) and with substances often present into tattoo dyes (ammonium chloride mercury, sulphate mercury (cinnabar), cadmium, cop- per, titanium, iron, chromium sulphate, chromium chloride, 2-[ethyl[4-[(4-nitro- phenyl)azo]phenyl]amino],4-(4-Nitrophen ylazo)aniline, Ethyl (2-mercaptobenzoato-S) mercury sodium salt, paraphenylendiamine ) showed a strong erythematous vesicular reac- tion (3+) to ammonium chloride mercury, cinnabar and Thimerosal after 48 hours. The patient refused the surgical removal of the tattoo. A topical therapy with clobetasol dipropionate twice daily was prescribed and at a three months follow-up visit the lesion appeared unchanged. Discussion Tattoing has become a common custom all over the world. Complications deriving from body tattoos are relatively uncommon if we think to the whole number of persons that recurs to this technique; they can consist in irritant and allergic contact dermatitis to tattoo dyes, development of lichenoid reactions and granulomatous responses such as sarcoid granulomas or foreign body granulomas.1,2 Also cases of discoid lupus erithematous have been reported.3 Skin pseudolymphoma is a reactive prolifer- ation of benign lymphocytes mimicking the histological and clinical features of a malig- nant lymphoma.2 The pathogenetic mechanisms are unclear. Pseudolymphomas can be secondary to med- ications, arhtropod bites, borrelia infections, vaccines, UV light and tattoo dyes and they may be caused by persistent allergic contact dermatitis or to the subcutaneous injection of allergens.4 Tattoo-induced pseudolymphomas are rare with fifteen cases reported so far.1,2,5 In these cases dye pigments in the dermis act as an antigen stimulus determining a prolifer- ation of lymphoid cells;5 they can appear from few months to 6 years after a tattoo place- ment.5 The most cases were described follow- ing red tattoos in patients with delayed contact sensitivity to Cinnabar (Mercuric Sulphate) but pseudolymphomas can occur also in blue (mainly cobalt salts) or green (mainly chrome salts) areas of tattoos.6 In the present case, a strong reaction to Cinnabar has been found together with positivities to other red pig- ments (e.g. red one disperse, ammonium chlo- Dermatology Reports 2011; volume 3:e47 Correspondence: Mariachiara Arisi, Department of Dermatology, Spedali Civili di Brescia, P.le Spedali Civili 1, 25123 Brescia, Italy. Tel. +39.030.399.5300 - Fax. +39.030.399.53015. E-mail: mariachiara.arisi@gmail.com Key words: pseudolymphoma, tattoo, allergic contact dermatitis. Received for publication: 18 July 2011. Revision received: 14 October 2011. Accepted for publication: 24 October 2011. This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BY- NC 3.0). ©Copyright G. Pasolini et al., 2011 Licensee PAGEPress, Italy Dermatology Reports 2011; 3:e47 doi:10.4081/dr.2011.e47 Figure 2. Scattered macrophages with small intracytoplasmic granules of brown pigment, fibrous reaction and focal ery- throcyte extravasations. Figure 1. Mildly itching plaque of the left leg. No n- co mm er cia l u se on ly [page 106] [Dermatology Reports 2011; 3:e47] ride mercury) and thimerosal as preservative. Tattoo pseudolymphomas have been traeted with topical or intralesional corticosteroids, surgical excision or laser treatment.7 A com- plete regression of the skin lesions has been described also after the assumption of hydrox- ycloroquine sulphate6 and a spontaneous remission of the disease has also been report- ed.5 In our case, at three months follow up skin lesions remained substantially unchanged despite a topical corticosteroid therapy and the patient was lost at follow-up. Altought pseudolymphoma is considered a benign disease7 a prolonged follow up is mandatory because of the reported hazard of progression of cutaneous pseudolymphoma to lymphoma. Sangueza et al. described the pro- gression of a tattoo- induced T-pseudolym- phoma, with 10-20% B-cells and characteris- tics of benign hystology, into a malignant mon- oclonal B-cell large lymphoma.8 References 1. Sowden JM, Byrne JP, Smith AG, et al. Red tattoo reactions: X-ray microanalysis and patch-test studies. Br J Dermatol 1991; 124:576-80. 2. Shin JB, Seo SH, Kim BK, Kim IH. Delayed Cutaneous T cell pseudolymphoma at the site of a semipermanent lip-liner tattoo. Dermatology 2009;218:75-8. 3. Kazandjieva J, Tsankov N. Tattoos: derma- tological complications. Clin Dermatol 2007;25:375-82. 4. Kuo WE, Richwine EE, Sheehan DJ. Pseudolymphomatous and lichenoid reac- tion to a red tattoo: a case report. Cutis 2011;87:89-92. 5. Gutermuth J, Hein R, Fend F, Ring J. Cutaneous Pseudolymphoma arising after tattoo placement. J Eur Acad Dermatol Venereol 2007;21:536-78. 6. Patrizi A, Raone B, Savoia F, et al. Tattoo- induced Psudolymphomatous reaction and its Successful Treatment with Hydro- xychloroquine. Acta derm Venereol 2009; 89:327-8. 7. Chiang C, Romero L. Cutaneous Lymphoid Hyperplasia (Pseudolymphoma) in a Tattoo After Far infrared Light. Derma- tologic Surg 2009;35:1434-8. 8. Sangueza OP, Yadav S, White CR Jr. Evolution of B-cell lymphoma from pseudo- lymphoma. A multidisciplinary approach using histology, immunohistochemistry, and Southern blot analysis. Am J Derma- topathol 1992;14:408-13. Case Report Figure 3. Immunohistochemical analysis showed a CD3+ and CD4+ lymphoid phe- notype No n- co mm er cia l u se on ly