Moles and melanomas on tattoos: Where we are in 2025

The recent letter by Kruczek et al. published in the Journal about melanomas on tattoos¹ brings further comments regarding the current state of knowledge on that specific topic.

First, the occurrence of a melanoma within a tattoo is still considered as a fortuitous event. The low number of case reports compared to the millions of tattooed individuals worldwide, the lack of cases of multiple melanomas arising within one tattoo and a mouse model showing that UV-induced skin cancers develop outside of black tattoos² are currently arguments against a direct link. It is important to remind that currently the sun exposure and sun protection habits of tattooed individuals have been rarely evaluated and disserve further large studies.³

Individuals with risks factors for melanoma such as personal or familial history of melanoma, numerous moles, atypical mole syndromes etc. should have a proper mapping of preexisting moles before tattooing and discuss which location may suit best according to mole density. The EADV Tattoo and body art task force has published a patient leaflet on that topic and is accessible on the EADV website. However, only 20% of melanomas on tattoos arise from preexisting moles.⁴

The challenges of moles and other pigmented lesions surveillance within tattoos are well known. A tattooed individual may not notice the arising of a new mole within a tattoo or neglect subtle clinical changes of a pigmented lesion. Dermatoscopy may be more difficult due to tattoo pigments deposition in the dermis, but it is far from being impossible (Figure 1). Kruczek et al. suggested the use of new tools such as reflectance confocal microscopy.¹ The cost benefits for the patient and the health care system compared to (unnecessary) excisions should be evaluated by clinical studies. Regular follow-up with clinical and dermatoscopy pictures followed by surgical excision whenever it appears necessary is the simplest course of action. Follow-up with medical skin imaging systems can be handy, nevertheless, the performance of artificial intelligence devices and apps when it comes to analysing pigmented lesions on tattoos has not been evaluated to my knowledge. Untrained AI apps that are available on the market for the public may ‘choose’ the worse diagnostic in doubt raising unnecessary stress for the app user. Scarring and distortion of the tattoo after excision remain secondary when it comes to suspicion of malignancy. A skilled dermatologic surgeon will try to conceal the surgical scar with the tattoo design if possible. However, a tattooed patient will understand the necessity of sacrificing the tattoo in this context.

Virtually any tattooed individual does have tattoo pigments in the draining lymph node of their tattoos. If macroscopically a tattooed ‘black’ lymph node appears greyish, the pathologist will distinguish with the help of adequate staining a melanoma metastasis from tattoo pigments.

Lastly, the role of tattooists in melanoma detection has been discussed elsewhere.⁵ The role of the tattooist should not be overstated. They must avoid tattooing on any preexisting unidentified skin lesion, especially pigmented ones, and scars of skin cancer surgery. They can discuss with the customers tattoo aftercare, sun protection, skin cancers and if necessary, suggest evaluation by the GP or the dermatologist. The dermatologist cannot examine systematically 20% of the population on the sole reason that they have tattoos. Only patients with the aforementioned risk factors should be examined by a dermatologist or in case of a suspect lesion within a tattoo.

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Consulting fees (Bioderma NAOS, La Roche Posay, Pierre Fabre) and Lectures (Pierre Fabre).

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