A three-dimensional tattoo: molluscum contagiosum

Twenty days after getting a tattoo on his arm, a 30-year-old immunocompetent man developed peculiar lesions at the tattoo site. He presented to our dermatology clinic three months later with umbilicated, skin-coloured, papular lesions that were asymptomatic (Figure 1A). His physical examination was otherwise normal and he had no clinical history of sexually transmitted diseases.

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Figure 1: (A) Skin-coloured papular lesions that are umbilicated and shiny, localized on the arm of a 30-year-old man, along the lines of a recent tattoo. (B) Microscopic view of a skin biopsy specimen (original magnification × 10) showing a crateriform-like appearance with keratinocytes containing characteristic eosinophilic inclusion bodies (asterisks) due to poxvirus infection. Depositions of black pigment are seen in the superficial dermis.

Serology results for syphilis, hepatitis B and C, and HIV were negative. Biopsy results confirmed our clinical diagnosis of molluscum contagiosum, with keratinocytes containing characteristic eosinophilic inclusion bodies due to poxvirus infection (Figure 1B). We presume that the molluscum contagiosum virus was inoculated by a contaminated needle.

Molluscum contagiosum, a viral infection most commonly observed in children, produces umbilicated papules in the epidermis. It is observed with a higher frequency in tropical climates, and predisposing conditions include atopic dermatitis, Darier disease and immunodeficiencies. In adults, molluscum contagiosum is recognized as a sexually transmitted disease. 1^,2 Common warts and condylomata acuminata are the most common differential diagnoses for multiple small lesions, especially if they occur in genital areas. 3^,4 In immunocompromised patients, deep fungal infections like cryptococcosis, penicilliosis, histoplasmosis and coccidiomycosis can be similar in presentation to the lesions of molluscum contagiosum. 2

Although in many patients lesions resolve spontaneously, active interventions can be divided into three categories: destructive (chemical and physical), immunomodulatory and antiviral. 5 The destructive approach (curettage, cryotherapy and topical application of keratolytic agents) is the most commonly used. We treated our patient’s lesions with multiple sessions of curettage, and we advised him to avoid skin-to-skin contact and to avoid shared towels and sheets.