Abstract
Decorative tattoos have been associated with many complications, including infections, inflammatory tattoo reactions, and koebnerization of inflammatory skin disorders. Several benign and malignant neoplasms have also been reported within tattoos. While there is a recent report of a patient who developed two desmoplastic intradermal Spitz nevi in a tattoo on her left arm, we report a patient who developed dozens of dermal Spitz nevi across multiple tattoos. A 42-year-old African American male presented with recent onset of asymptomatic lesions on both forearms within tattoos; examination showed 24 hyperpigmented papules, sometimes coalescing, limited to the black and red portions of decorative tattoos on his extensor forearms. Punch biopsies of two lesions showed papillomatosis with scattered strands of monomorphic spindle cells in the superficial dermis admixed with macrophages containing black and red tattoo pigments. The spindle cells were positive for SOX10, MITF and S100. Dermal Spitz nevi, atypical Spitz tumors (AST) and Spitzoid melanomas (SM) were considered. However, unlike AST and SM, pleomorphism and high mitotic activity were absent and there was a very low proliferative index by Ki-67. Tattoo pigments contain potential carcinogens and can act as a hapten or foreign bodies in allergic and papulonodular reactions, respectively, although the pathogenesis of tattoo-associated dermal Spitz nevi is still unknown. The architecture and cytology, and immunostaining patterns were most consistent with numerous spindle cell dermal Spitz nevi occurring within tattoos. We present this case to document our findings and emphasize a rare potential complication of decorative tattoos.