Department of Dermatology, Hospital Universitario San Cecilio, Granada, Spain *Corresponding Author’s e-mail: ismenios@hotmail.com آثليل التنني لورا ليناري�س غونزالي�س، فران�سي�سكو نافارو تريفينيو، ريكاردو رويز فيالفريدي Dragon Warts Laura Linares-Gonzalez, Francisco Navarro-Triviño, *Ricardo Ruiz-Villaverde Sultan Qaboos University Med J, November 2020, Vol. 20, Iss. 4, pp. e397–398, Epub. 21 Dec 20 Submitted 27 Jan 20 Revision Req. 27 Apr 20; Revision Recd. 28 Apr 20 Accepted 20 May 20 A 31-year-old male patient with a personal history of type-1 diabetes presented to the dermatological outpatient clinic in Hospital Universitario San Cecilio, Granada, Spain in January 2020, with asymptomatic, multiple, skin-colored papules of different sizes within a black tattoo on his abdomen [Figure 1]. The tattoo was done 15 years ago and the lesions developed one year after on the lines of the tattoo and remained exclusively confined to it. However, the patient did not seek medical attention for the papules on his tattoo. Dermatoscopy showed skin-coloured homogeneous papilomatous papules; laboratory investigations were within normal limits [Figure 2]. Complimentary tests such as blood cell count test, general biochemistry, autoantibodies, angiotensin converting enzyme, erythrocyte sedimentation rate, C-reactive protein complement, immunoglobulins, urinalysis were within normal limits. The histological findings were consistent with verruca vulgaris. Patient consent was obtained for publication of the images. Comment As tattooing has spread worldwide, the number of medical consultations regarding its side effects has increased. Although the most common reactions to tattoos are inflammatory reactions, a variety of infectious diseases including bacterial and viral infections has also been described.1 The first formal report of in a tattoo dates back to 1884.2 Most reports seem to be confined to certain colours used multicoloured tattoos, with a clear preference for black ink.3 In the current case, the distribution of warts over the black ink along with the This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License. https://doi.org/10.18295/squmj.2020.20.04.020 interesting medical image Figure 1: Skin-coloured papules on a black tattoo of the abdomen of a 31-year-old male patient who presented to the dermatological outpatient clinic in Hospital Universitario San Cecilio, Granada, Spain. https://creativecommons.org/licenses/by-nd/4.0/ Dragon Warts e398 | SQU Medical Journal, November 2020, Volume 20, Issue 4 surrounding normal skin raised suspicion regarding the localisation of the warts. In the current case, the source of infection was difficult to determine. However, it has been proposed that it was the result of contaminated ink or other contaminated materials or instruments, implantation of viral particles present in the saliva of the tattoo artist during the procedure or autoinoculation of the patient’s own wart by tattooing through virally contaminated skin.4 Another possibility is that the infection was already present before tattooing. An interesting theory suggests that virus replication might have been activated by mechanical impairment of the skin barrier. In most cases, lesions could be observed several months or years after tattooing.5 The longest latency period between tattooing and the manifestations of human papillomavirus (HPV) infection was 10 years. This suggests that the immune system is able to control the infection and that the development of cutaneous viral warts could depend on a local persistent dysregulation of the skin immune system. In addition, delayed activation of HPV and induction of warts in a tattoo has also been described after sunlight exposure implying that HPV can be triggered by external stressors.5 Another explanation to this phenomena is that the tattooed area becomes an immunocompromised district. An immunocompromised district is a site which is particularly susceptible to subsequent outbreaks of opportunistic infections, tumours and immune disorders confined to the district itself.6,7 A simple physical examination will easily suggest the correct diagnosis in most cases. However, dermatoscopy is a useful adjuntive tool when clinical diagnosis is not clear or if histological images are inconclusive or not available. References 1. Messahel A, Musgrove B. Infective complications of tattooing and skin piercing. J Infect Public Health 2009; 2:7–13. https:// doi.org/10.1016/j.jiph.2009.01.006. 2. Fox, TC. Warts Occurring on Tattooed Lines. J Cutan Vener Dis 1884; 2:216. 3. Baxter SY, Deck DH. Tattoo-acquired verrucae plana. Am Fam Physician 1993; 47: 732. 4. Ragland HP, Hubbell C, Stewart KR, Nesbitt LT. Verruca vulgaris inoculated during tattoo placement. Int J Dermatol 1994; 33:796–7. https://doi.org/10.1111/j.1365-4362.1994.tb00998.x. 5. Wanat KA, Tyring S, Rady P, Kovarik CL. Human papillomavirus type 27 associated with multiple verruca within a tattoo: report of a case and review of the literature. Int J Derm 2014; 53:882–4. https://doi.org/10.1111/j.1365-4632.2012.05644.x. 6. Ruocco V, Brunetti G, Puca RV, Ruocco E. The immuno- compromised district: A unifying concept for lymphoedematous, herpes-infected and otherwise damaged sites. J Eur Acad Dermatol Venereol 2009; 23:1364–73. https://doi.org/10.1111/ j.1468-3083.2009.03345.x. 7. Ruocco V, Ruocco E, Piccolo V, Brunetti G, Guerrera LP, Wolf R. The immunocompromised district in dermatology: A unifying pathogenic view of the regional immune dysregulation. Clin Dermatol 2014; 32:569–76. https://doi.org/10.1016/j. clindermatol.2014.04.004. Figure 2: Dermatoscopy at x10 magnification showing skin-coloured homogeneous papilomatous papules on the black tattoo of a 31-year-old male patient. https://doi.org/10.1016/j.jiph.2009.01.006 https://doi.org/10.1016/j.jiph.2009.01.006 https://doi.org/10.1111/j.1365-4362.1994.tb00998.x https://doi.org/10.1111/j.1365-4632.2012.05644.x https://doi.org/10.1111/j.1468-3083.2009.03345.x https://doi.org/10.1111/j.1468-3083.2009.03345.x https://doi.org/10.1016/j.clindermatol.2014.04.004 https://doi.org/10.1016/j.clindermatol.2014.04.004