Association of hidradenitis suppurativa disease severity with increased risk for systemic comorbidities

DEAR EDITOR, I read with interest the recent report by Haus et al. about a patient who developed two lesions of lymphomatoid papulosis (LyP) on the red parts of a tattoo. However, their report deserves a few comments. Many reported pseudolymphomas on tattoos involve T cells or both T and B cells, and are not attributed ‘mainly’ to B cells, as described in the manuscript. To date, Sangueza et al. in 1992 have published the only well-documented report of the malignant transformation of a T-cell pseudolymphoma into a monoclonal B-cell lymphoma related to a chronic tattoo reaction. It is widely accepted that mercury has disappeared from red ink manufacturing. Despite withdrawal of mercury, red tattoo reactions, including pseudolymphoma, still occur, raising the question of the culprit component or by-product leading to such reactions. Beyond the nosological issues that the authors try to discuss (LyP or pseudolymphoma), the present case illustrates an increasingly frequent situation due to the popularity of tattoos, namely the occurrence of coincidental dermatological conditions in tattooed individuals. Indeed, in the vast majority of cases of both pseudolymphoma and other ‘allergic’ reactions, tattoos display either a complete infiltration of the whole culprit colour or an infiltration made by more or less distinct papules or nodules restricted to one colour. A tattoo ‘allergy’ does not present as one, two or three single lesions on a very little part of the culprit colour. It is hard to conceive that a chronic stimulation of a clonal subset of lymphocytes against a specific component of the colour would be responsible for only an extremely limited reaction on two distant parts of such a wildly coloured area as reported by Haus et al. Besides, despite being rare, localized LyP happens more often among the young. It seems rather likely that this patient developed a localized LyP on a fortuitous tattooed area. One could argue the possible presence of specific impurities located specifically on both areas that could have selected a monoclonal population, but it is pushing the speculation rather far, especially as the reaction spontaneously resolved after 2 months and the patient has now been disease free for the past 1 5 years. Pseudolymphomas on tattoos may indeed regress spontaneously, but they usually follow a protracted course in the absence of any treatment. The number of anecdotal reactions on tattoos will keep on increasing with the popularity of tattoos and the ageing of the tattooed population, due to a fortuitous coexistence of a skin condition and the tattoo. LyP on a tattoo seems to be one of them.