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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 167-169

Basal cell carcinoma arising in a tattoo


Department of Dermatology, University of Virginia School of Medicine, Charlottesville, Virginia, USA

Date of Submission17-Jun-2019
Date of Acceptance18-Nov-2019
Date of Web Publication18-Aug-2020

Correspondence Address:
Nicole Edmonds
1221 Lee St., P.O. Box 800718, UVA Health System, Charlottesville, VA 22908-0718
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_24_19

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  Abstract 


Cutaneous malignancies may uncommonly arise in the setting of injury to the skin from a variety of etiologies. While melanoma, squamous cell carcinoma, and basal cell carcinoma (BCC) have all been reported at tattoo sites, BCC is the least common, with the present case being only the 12th such case reported in the literature. We present a case of a large BCC of 15 years duration arising within a blue/black tattoo on the patient's left upper arm. The patient was treated with 6 weeks of imiquimod cream with promising results and started a second 6-week regimen to clear residual tumor. Of the 12 reported cases of BCC arising within tattoo sites, the majority of patients have been male (7/12 patients) and the majority of the BCCs developed within the blue or black pigment of the tattoo (8/12 patients) on sun-exposed skin (9/12 patients). The average age at the diagnosis is 53.5 years, and the average duration between tattoo placement and BCC onset is 18.3 years. It has been hypothesized that tattoo ink may be related to the development of malignancies as either a primary carcinogen or cocarcinogen with ultraviolet exposure. Nevertheless, the link between tattoo ink and malignancy may also be coincidental considering the number of tattooed individuals worldwide and the extreme rarity of BCCs that have developed in tattoos. Our purpose is to raise the awareness of the development of cutaneous malignancies within tattoo sites and encourage the physicians to include cutaneous malignancy in the differential diagnosis of “rash” arising in a tattoo.

Keywords: Basal cell carcinoma, pigments, tattoo, ultraviolet exposure


How to cite this article:
Edmonds N, Cropley T, Noland MM, Flowers RH. Basal cell carcinoma arising in a tattoo. Clin Dermatol Rev 2020;4:167-9

How to cite this URL:
Edmonds N, Cropley T, Noland MM, Flowers RH. Basal cell carcinoma arising in a tattoo. Clin Dermatol Rev [serial online] 2020 [cited 2020 Sep 22];4:167-9. Available from: http://www.cdriadvlkn.org/text.asp?2020/4/2/167/292468




  Introduction Top


Tattooing, defined as the introduction of exogenous pigment and dye into the dermis, has a prevalence of approximately 25% among 18–50 years old in the United States.[1] Melanoma, basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and keratoacanthoma have all been reported at the sites of tattoo, though BCC is the least common.[1] Although cutaneous malignancy may uncommonly arise in the setting of injury to the skin, it remains unclear what role tattoos play in the pathogenesis of these malignancies.[2] We present a case of a large BCC arising at the site of a tattoo, which is the 12th reported case in the literature. Our purpose is to encourage the physicians to include cutaneous malignancy in the differential diagnosis of “rash” arising in a tattoo and also to report topical imiquimod as a novel and potentially effective therapy in this setting.


  Case Report Top


A 51-year-old incarcerated Caucasian male presented in June 2018 with a 15-year history of a growing lesion on his left upper arm, arising within a tattoo he obtained as a youth. Treatment with topical steroids, emollients, and antifungals proved ineffective. On examination, he had an 8-cm scaly erythematous plaque overlying the blue and black pigment of a large tattoo [Figure 1]. The patient had no history of skin disease and specifically denied any history of psoriasis or eczema. Initial differential diagnosis included tattoo pigment reaction, sarcoidosis, cutaneous T-cell lymphoma, tinea corporis, infection, and psoriasis. After he failed to respond to 2 weeks of ultrapotent topical steroid, biopsy revealed superficial and nodular BCC [Figure 2] and [Figure 3]. Due to the size of the lesion, the patient was treated with 6 weeks of imiquimod 5% cream, applied 5 days a week with partial clearance [Figure 4]. The patient has been started on another 6 weeks of imiquimod 5% cream to clear residual tumor.
Figure 1: Within a large tattoo on the left upper arm is a thin scaly pink plaque with overlying crusting and erosion centrally

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Figure 2: Basal cell carcinoma evident in the epidermis, with black tattoo pigment in the reticular dermis (×4)

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Figure 3: High-power view (×10) of basal cell carcinoma

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Figure 4: Follow-up image of basal cell carcinoma after initial 6 weeks of topical imiquimod therapy

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  Discussion Top


Cutaneous lesions occurring at the sites of tattoo include benign (allergic reactions, verrucae, and sarcoidosis) and malignant (melanoma, SCC, and BCC) lesions. Of those malignant growths, BCCs are the least reported.[3] Including our case, BCCs have been reported to arise within tattoos in 12 cases [Table 1]. Of the 12 reported cases, the majority of patients were male (7/12 patients) and the majority of the BCCs developed within the blue or black pigment of the tattoo (8/12 patients) on sun-exposed skin (9/12 patients). The average age at the diagnosis is 53.5 years, and the average duration between tattoo placement and BCC onset is 18.3 years. The majority of the patients denied any history of prior malignancy. Nevertheless, BCC arising in tattoo sites is a very rare occurrence, and drawing conclusions from a few cases is difficult.
Table 1: Overview of BCC in tattoo sites currently in the literature

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The relationship between cutaneous malignancy and tattoo pigment has yet to be elucidated. Considering the number of individuals tattooed worldwide and the extreme rarity of BCC that has developed in tattoos, this occurrence may well be coincidental.[1] However, tattoos may act as either primary carcinogens or cocarcinogens with ultraviolet (UV) exposure.[4] One possible explanation for the carcinogenesis of tattoos is that the trauma from the tattoo may lead to subsequent tumor development. Potential mechanisms include localized nutritional deficiency at the site of tissue injury, scar tissue that alters or modifies the immune pathway, chronic release of toxins from the site of the tattoo leading to the mutation of cells, as well as chronic irritation.[5] Another mechanism posits the tattoo pigment itself is carcinogenic. Tattoo pigment in the dermis may induce malignant changes that result in sustained and prolonged efforts of tissue repair. It is unclear whether the skin is able to metabolize tattoo ink byproducts. The precise composition of tattoo inks is not regulated, and the U.S. Food and Drug Administration has not approved any ink for use in tattooing. More recently, azo compounds, some of which are known carcinogens, have been introduced into tattoo ink as an organic colorant and are now the primary organic colorant in 60% of tattoo inks.[1] The age of onset of BCC arising in tattoos has been decreasing, which could be related to the change in composition of the tattoo inks.[1]

Finally, tissue trauma/pigment toxicity may interact with UV exposure to contribute to tumor development. Tissue already primed for tumor development by UV radiation may be stimulated further by tissue trauma from a tattoo. Trauma may also sensitize the area to sunlight due to poor vascularity and elasticity of damaged tissue.[6] Tattoo pigments, on the other hand, could alter UV absorption in the skin, which might explain why the current trend in BCC development in tattoos has been in the darker pigments.[2] The answer may even be simpler than that. Perhaps, tattooed individuals would want to display their tattoos, thereby exposing them to the sun.[6] Conversely, tattooed individuals may also shield their tattoos from the sun to prevent fading the colors, which may account for such a low number of BCCs arising within them. Nevertheless, if there is a true link between tattoos and malignancies, its carcinogenesis is likely multifactorial.


  Conclusion Top


Although uncommon, BCCs may arise within long-standing tattoos and mimic a variety of cutaneous diseases. Although the relationship between cutaneous malignancy and tattoo pigment may be coincidental, physicians should consider cutaneous malignancy in their differential diagnosis of cutaneous lesions within a tattoo. Trauma-related tumors can be especially deceptive clinically and raising awareness of the occurrence may benefit future patients.[6]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.[10]



 
  References Top

1.
Kluger N, Koljonen V. Tattoos, inks, and cancer. Lancet Oncol 2012;13:e161-8.  Back to cited text no. 1
    
2.
Wiener DA, Scher RK. Basal cell carcinoma arising in a tattoo. Cutis 1987;39:125-6.  Back to cited text no. 2
    
3.
Kluger N, Phan A, Debarbieux S, Balme B, Thomas L. Skin cancers arising in tattoos: Coincidental or not? Dermatology 2008;217:219-21.  Back to cited text no. 3
    
4.
Doumat F, Kaise W, Barbaud A, Schmutz JL. Basal cell carcinoma in a tattoo. Dermatology 2004;208:181-2.  Back to cited text no. 4
    
5.
Lee JS, Park J, Kim SM, Yun SK, Kim HU. Basal cell carcinoma arising in a tattooed eyebrow. Ann Dermatol 2009;21:281-4.  Back to cited text no. 5
    
6.
Noodleman FR, Pollack SV. Trauma as a possible etiologic factor in basal cell carcinoma. J Dermatol Surg Oncol 1986;12:841-6.  Back to cited text no. 6
    
7.
Bashir AH. Basal cell carcinoma in tattoos: Report of two cases. Br J Plast Surg 1976;29:288-90.  Back to cited text no. 7
    
8.
Earley MJ. Basal cell carcinoma arising in tattoos: A clinical report of two cases. Br J Plast Surg 1983;36:258-9.  Back to cited text no. 8
    
9.
Birnie AJ, Kulkarni K, Varma S. Basal cell carcinoma arising in a tattoo. Clini Exp Dermatol 2006;31:820-1.   Back to cited text no. 9
    
10.
Omidian M, Emad-Mostofi N. Photoclinic diagnosis: Basal cell carcinoma arising from traditional tattoo. Arch Iran Med 2009;12:198.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

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