Cutaneous
infections can occur on
tattoos.
Tattoo-associated
viral infections can be caused by human papillomavirus. A
verruca vulgaris developed on the
tattoo of a 44-year-old woman; the viral lesion appeared 21 years after she received the
tattoo and had been increasing in size during the prior five years. Biopsy of the lesion not only confirmed the diagnosis but also removed most of the
wart; the patient declined any additional treatment. In addition to
verruca vulgaris (27 individuals),
verruca plana (14 individuals) and human immunodeficiency virus-associated acquired
epidermodysplasia verruciformis (two men) are human papillomavirus lesions that have been observed to occur on
tattoos. The latency period from receiving the
tattoo to the appearance of the
wart has ranged from one month to 21 years; the median duration was 21 months for
verruca vulgaris and 24 months for
verruca plana. The
warts most frequently appeared in the dark, usually black, inked areas of the
tattoo; indeed, it has been postulated that the ink created a cutaneous immunocompromised district that enhanced the opportunity for the viral lesions to occur in the
tattoo. The use of contaminated instruments or ink during
tattoo inoculation is the most likely etiology for the development of a
wart on a
tattoo. However, other potential mechanisms for human papillomavirus to occur on a
tattoo include transmission of the virus from the
tattoo artist's ungloved hand or saliva, a preexisting (albeit unrecognized) human papillomavirus lesion adjacent to or at the site of the
tattoo, and postinoculation acquisition of the
verruca at the site of the
tattoo. Topical
retinoid or
imiquimod, used as a single agent, was not effective in the treatment of the
warts. Some of the patients who were treated with
cryotherapy using liquid
nitrogen did not achieve any improvement of their viral lesions. However, other patients observed resolution of most or all their
warts when
cryotherapy with liquid
nitrogen, either as monotherapy or followed by topical application of 5%
imiquimod cream, was used; yet, following treatment, these individuals experienced mild distortion of their
tattoo and/or
hypopigmentation.
Curettage and
squaric acid dibutyl ester contact
immunotherapy were both successful approaches to the management of
tattoo-associated
warts. In addition,
warts were efficaciously managed with either
photodynamic therapy or treatment with an ablative
erbium:
yttrium aluminum garnet (
YAG) laser followed by topical application of 5%
imiquimod cream.