Tattoo-Associated Viral Infections: A Review

Figures & data

Table 1 Viral Infections and Tattoos

Virus	Reference
Hepatitis B virus	[^Citation4^–^Citation6]
Hepatitis C virus	[^Citation4,Citation6^–^Citation8]
Herpes simplex virus	[^Citation9^–^Citation11]
Human immunodeficiency virus	[^Citation4,Citation12,Citation13]
Human papillomavirus	[^Citation3,Citation14,Citation15,Citation33^–^Citation35]
Molluscum contagiosum virus	[^Citation16^–^Citation29]
Rubella (German measles) virus	[^Citation30]
Vaccinia (smallpox) virus	[^Citation31,Citation32]

Table 2 Tattoo-Associated Herpes Compunctorum

C	Age Sex	PCR	Path	AT	Comments	Ref
1	30y M	+HSV-1	1°	F	Severe neuropathic pain, three days after extensive tattooing of the left arm. He had neither prior HSV (oral or genital) infection nor complications after previous tattooing. He presented with a low grade fever (37.9°C) and vesicles mainly in the shaded areas of the tattoo with minimal spread outside the tattooed areas. HSV-1 serology was positive for both IgM and IgG; lesion bacterial culture also grew MSSA.	[^Citation9]
2	31y W	+HSV-1 -VZV	1°	V	Acute painful and itchy clustered and scattered pustules developed around a black tattoo on the right flank three days after tattooing. She became febrile (38.2°C) and presented for treatment four days later. Systemic antiviral and empiric antibacterial (cloxacillin, one gram twice daily) therapy, and topical chlorhexidine was initiated; five days later, she had dry pustules, no fever, and no new lesions.	[^Citation10]
3	46y W	NS	2°	A	Vesicles developed at the sites of inking on both the upper and lower lips two days after tattooing; fever and itching (that progressed to a burning sensation and pain) also developed. Her retro-auricular lymph nodes also enlarged. By day four post-tattooing, she was receiving systemic and topical antiviral therapy, and topical tetracycline ointment. After one week, there was complete healing.	[^Citation11]

Abbreviations: A, acyclovir (800 mg TID, PO and topical ointment); AT, antiviral therapy; BID, twice daily; C, case; F, famciclovir (250 mg TID, PO); HSV-1, herpes simplex virus type 1; M, man; mg, milligrams; MSSA, methicillin-sensitive Staphylococcus aureus; NS, not stated; Path, pathogenesis; PCR, polymerase chain reaction (of pustule or vesicular fluid); PO, orally; Ref, reference; TID, three times daily; V, valacyclovir (500 mg BID, PO); VZV, varicella-zoster virus; W, woman; y, years; 1°, primary infection via inoculation; 2°, secondary reactivation; +, positive; -, negative.

Table 3 Tattoo-Associated Human Immunodeficiency Virus Infection

Feature	Case 1	Case 2	Case 3
Age	26-years-old	30-years-old	31-years-old
Sex	Man	Woman	Man
CC	Easy bruising	None	Ataxia, falling, hypoaesthesia, leg shaking and weakness
Dx	HIV-associated thrombocytopenia	Antenatal pregnancy screening	HIV-associated myelopathy
HIV Ab	+ ELISA, + Western blot	+ ELISA, + Western blot	+
HIV RF
BT	–	–	–
HSA	–	–	–
IVDA	–	–	–
SWP	–	–	+
Tattoo	+, in prison	+, cosmetic at home	+, in prison
Ref	case 1 [^Citation12]	[^Citation13]	case 2 [^Citation12]

Abbreviations: Ab, antibody; BT, blood transfusion; CC, chief complaint, Dx, diagnosis, HIV, human immunodeficiency virus; HSA, homosexual activity; IVDA, intravenous drug abuse; Ref, reference; RF, risk factor; SWP, sex with prostitutes.

Table 4 Tattoo-Associated Human Papillomavirus Infections

Feature	Acquired Epidermodysplasia Verruciformis	Verruca Plana	Verruca Vulgaris
Number of cases	2	14	29^a
Onset age (years): range (median)	29–44 (37)	20–48 (30)	17–66 (28)
Number of men	2	5	14
Onset age (years): range (median)	29–44 (37)	20–48, (33)	18–39 (35)
Number of women	0	3	4
Onset age (years): range (median)		21–39 (27)	17–66 (38)
Tattoo artist: professional/amateur	2/0	5/2	15/2^b
Tattoo duration^c (months): range (median)	Not stated	6–234 (24)^c	1–252 (21)^c
Number of lesions	Multiple	Multiple^d	Multiple^e
Tattoo location (number of patients)	Arm and forearm (1) Back (1)	Extremity (5) Chest (1) Eyebrow (1)	Extremity (12)^f Scapula (3) Abdomen (1) Eyebrows (1)
Tattoo color (number of patients)	Black and red (1) Dark grey (1)	Black (6) Dark blue (1)	Black (21)^g Blue (4) Dark (2) Green (2) Red (2) Grey (1) Indigo (1) Multicolored (1)
Biopsy for diagnosis (number of patients)	+ (2)	+ (7)	+15^h
Successful treatments (number of patients)	Photodynamic therapy (1)^i	Curettage (1) LN2 for three sessions and 5% imiquimod cream (1)	LN2 (2)^j SADBE CI (2)^k Curettage (1) Laser and 5% imiquimod cream (1)^l

Notes: ^aThese include the 27 patients summarized in a recent review¹⁵ and two additional cases presented only as images: (1) the legend states “viral warts restricted to tattooed areas” from a figure demonstrating warts on the “FS*” tattoo attributed to dermatologist Dr. Sylvain Reberga from Toulouse, France¹⁴ and (2) the legends state “papilloma virus infection after tattooing” that shows warts on a tattoo and “Koebner phenomenon on the same arm” showing a linear arrangement of warts not associated with the tattoo.³ bThe status of the tattoo artist was not stated for one young man from England who had his tattoo applied by an Italian in Port Elizabeth (which has since been renamed Gqeberha) in South Africa. ^cTattoo duration is the number of months after tattoo placement that the wart appeared. The verruca plana appeared within two years after tattoo inoculation for 57% (four of seven) of the patients. The verruca vulgaris appeared within three years after tattoo acquisition for 70% (12 of 17) of the patients. ^dThe number of verruca plana, when described, were: more than two, 120, 150, and 100’s. ^eThe number of verruca vulgaris, when described, ranged from one to greater than 400 (median, 17). ^fFour of the patients also had warts that were not associated with their tattoo previously (on the back, one patient)¹⁵ or concurrently: either on the same arm (one patient)⁵ or perianal or genital (two patients).¹⁵ gFive of the patients had warts on more than one tattoo color: black and blue, black and dark grey, black and green, dark (not otherwise specified) and red, and green and red. ^hThree of the 15 patients also had dermoscopy evaluation of their warts. However, 44% (12 of 27) patients had their wart diagnosed clinically, based on the morphology of the lesion. ⁱPhotodynamic therapy consisted of three hours of skin incubation with topical methyl aminolevulinate (MAL) followed by illuminating the epidermodysplasia verruciformis lesions using a red-light source (635 nanometers) from a light emitting diode (LED) with a fluence of 37 Joules/cm². Sessions were performed at three-week intervals; after three sessions all of the viral lesions had completely resolved and had not recur at follow-up two years later. ^jCryotherapy, using liquid nitrogen, resulted in ablation of most or all the warts; however, mild distortion of the tattoo and/or post-treatment hypopigmentation occurred. ^kSADBE contact immunotherapy involves sensitization (by applying 100 microliter of 2% SADBE to 10-centimeters² area of the volar aspect of the uninvolved arm for 48 hours) and weekly treatment (by applying 100 microliters of 0.01% SADBE directly on the warts) beginning two weeks later. All of the verruca vulgaris resolved after eight or 10 weeks of treatment; there was no scar, no pigmentary alteration, and no recurrence of the viral lesions during a follow-up period of 10 months. ^lAblative erbium:yttrium aluminum garnet (YAG) laser treatment (one session) resulted in 80% resolution of the wart; the residual lesion resolved after 12 weeks of daily 5% imiquimod cream application.

Abbreviations: CI, contact immunotherapy; LN2, liquid nitrogen cryotherapy; SADBE, squaric acid dibutylester; +, positive or present; %, percent.

Figure 1 Tattoo-associated human papillomavirus infection. Distant (A) and closer (B) views of the left ankle of a 44-year-old woman show a verruca vulgaris (black arrow) that has developed on the black inked tattoo. She received her tattoo when she was 18 years old; the asymptomatic wart that developed within her tattoo appeared five years ago–26 years after tattoo inoculation–and subsequently increased in size. The patient’s tattoo-associated verruca vulgaris has been reported.¹⁵

Table 5 Tattoo-Associated Molluscum Contagiosum Virus Infection

C^a	A Na G	TD PT	NOL	Bx	Site	Tattoo Color	IC HB, HC HIV, Sy	Txment	Ref
1	20 It W	3 +	10	+	Left Forearm	Black	+ -, - -, -	None (patient refused)	[^Citation16]
2	20 En M	12 +	Sev	+	Left Upper Arm	Black^b	+ NS, NS NS, NS	None (resol spont within 6 months)	[^Citation17]
3	20 Sp M	20^c +	Sev	+	Left Calf	Brown- Grey^d	+ -, - -, -	NS	[^Citation18]
4	22 Bz M	20^e +	50	+	Back	Black	+ -, - -, -	Curettage	[^Citation19]
5	23 Sp M	NS +	Sev	+	Right Abdom Flank	Black	+ -, - -, -	Curettage (mult sess) Not recur	[^Citation20]
6	24 It M	2 +	Sev	-CD Dm	Right Lumbar	Black	+ NS, NS NS, NS	Curettage	[^Citation21]
7	30 It M	3 +	Mny	+	Arm	Black	+ -, - -, -	Curettage (mult sess)	[^Citation22]
8	33 Sp M	20 +	Sev	-CD	Right Upper Arm	Black Blue Red	+ -, - -, -	NS	[^Citation23]
9	33 Sp M	12-	Sev^f	-CD	Right Arm	Black	+ -, - -, -	Curettage	[^Citation24]
10	36 Sp M	3^g +	Sev	+	Right Arm	Black	+ -, - -, NS	Curettage Not recur	[^Citation25]
11	59 Fr M	24 +	20	-CD	Chest	Black	+ NS, - -, NS	None (patient refused)	[^Citation26]

Notes: ^aCase 12 is the initial description of molluscum contagiosum included in a tattoo; it is discussed in an article by Dr. J. Ullmann that was written in German and published in 1903 in Monatshefte fur Praktische Dermatologie titled “About peculiar tumor formation in a tattoo mark”.²⁷ The paper credits the observation of Dr. Bergh but does not provide specific details regarding the patient: “Professor Bergh in Copenhagen, as I received a written letter from him, also saw acne varioliformis and molluscum contagiosum included in the process, while he is not aware of the changes I have described below. The tattoo can therefore, under certain circumstances, have been unfortunate for the individual provided with the colorful jewelry”. Unfortunately, both Perez-Barrio et al²⁵ and Panasiti et al²¹ erroneously cited Dr. Bergh as the author of this paper. Case 13 is contributed by Drs. Kiang and Bang;²⁸ the investigators published an abstract about infectious diseases arising in new tattoos. Specifically, they commented that “Infectious diseases arising within tattoos occur rarely …. We present two interesting cases of infectious diseases complicating new tattoos. The first patient developed a collection of papules within a recently colored tattoo. Biopsy of a papule was consistent with molluscum contagiosum …. These cases highlight the potential health risks posed by this popular form of body art. Unfortunately, Perez-Barrio et al²⁵ incorrectly cited the paper in the reference section of their article. Case 14 is a clinical image included in a review article by Kluger.²⁹ The image, titled “Molluscum contagiosum on a tattoo” was contributed from the collection of dermatologist Dr. Nicole Jouan from Brest, France. ^bThe tattoo was performed using carbon, scarlet late, and chlorinated copper pigments. Molluscum contagiosum only appeared in the black pigment which consisted of charcoal suspended in ammoniacal solution containing phenol. ^cThe tattoo was done in three sessions (at two-week intervals): (1) black ink used to draw the picture lines, (2) brownish-grey pigment for background of the drawing, and (3) other colors to fill in the figure ^dMolluscum contagiosum only occurred in the brownish-grey ink of the picture base. It was neither in the picture lines (black ink) or pigment filling the figure (other colors). ^eThe tattoo was done in various sessions within a total period of four months. ^fThe molluscum contagiosum presented as pruritic lesions. ^gThere was progressive loss of pigment from the original tattoo that had been performed several years earlier with no associated problems; the molluscum contagiosum appeared three weeks after a recoloring procedure had been done.

Abbreviations: A, age (years); Abdom, abdominal; Bx, biopsy confirmation of molluscum contagiosum diagnosis; Bz, Brazilian; C, case; CD, clinical diagnosis; DM, dermoscopy; En, English; Fr, French; G, gender; HB, hepatitis B virus; HC, hepatitis C virus; HIV, human immunodeficiency virus; IC, immunocompetent; It, Italian; M, man; Mny, many; Na, nationality; NOL, number of lesions; NS, not stated; PT, professional tattoo; Ref, reference; Resol, resolved; Sess, sessions; Sev, several; Sp, Spanish; Spont, spontaneously; Sy, syphilis; TD, tattoo duration (number of weeks after tattoo placement that molluscum contagiosum lesion appeared); Txment, treatment; W, Woman, +, positive; -, negative.

Table 6 Tattoo-Associated Vaccinia (Smallpox) Autoinoculation

C	Age Race Sex	Comments	Ref
1	21y AA Man	A large tattoo–whose duration was not stated–had been present on the soldier’s left shoulder. Four days after receiving smallpox vaccine inoculation within the tattoo located on his left deltoid, he had a touch up of the tattoo which included the area directly over the inoculation site. Soon after receiving the tattoo touch up, his entire left shoulder became pruritic and he developed many bumps within and around both the newly added and previously existing tattoo. Subsequently, the flesh-colored, less than 2-millimeter, papules (and vesicle at the inoculation site) became umbilicated, crusted, and exudative with a yellow discharge; he also experienced fever and increased pain of his erythematous left shoulder. He was empirically treated with trimethoprim-sulfamethoxazole for a suspected MRSA infection; within two days, the erythema resolved, he was afebrile, and the previous lesions on his pain-free left shoulder had scabbed. The affected area healed within 23 days after tattoo touch up (and 27 days after vaccine inoculation) with hypopigmented scarring.	[^Citation31]
2	23y NS Man	The soldier’s left upper arm received a tattoo that “ … consisted of a scantily bedecked, but liberally bepainted female, enwreathed in dice, cards, guns, knives, and bottles, the whole bearing the caption Man’s Ruin.” His upper arm subsequently became tender and swollen; this reaction resolved within three weeks and he was vaccinated near the upper edge of the tattoo. Blisters developed in the area of the tattoo adjacent to the vaccination site after three days. The blisters spread “ … rapidly until both the lady and her halo were completely submerged beneath a flood of vesication, and reduced to an indistinguishable blob.” Thereafter, “ … the customary phases of an orthodox vaccination [occurred], although on a scale usually associated only with the calf in the laboratory.” A five by eight centimeter quadrilateral area of “ … dark brown, adherent and deeply wrinkled crust, resembling that which forms on a can of derived varnish … ” developed and “ … during the second week this peeled off almost whole, leaving a thin pink cicatrix beneath, but both the lady and her satellites were found to have passed into history.”	[^Citation32]

Abbreviations: AA, African American; C, case; MRSA, methicillin-resistant Staphylococcus aureus; NS, not stated; Ref, reference; y, years.

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