To the best of our knowledge

To the best of our knowledge, this is the first case report and small outbreak of M. abscessus cutaneous infection associated with tattoos in Taiwan. We emphasize vigilance for healthcare providers to include NTM infection in the differential diagnosis when seeing patients with skin rashes after tattooing. We also suggest a need for the Department of Health to establish regulations for safe tattoo practices.
Port-wine stains (PWSs) are vascular malformations characterized by dilatation of tachykinin receptor of the upper dermis. They are usually considered as congenital disorders that often present as pinkish to purple macules at birth and progress to darker and elevated lesions as time progresses. The etiology of PWS is unclear but may be related to autonomic dysfunction. A 47-year-old man presented with erythematous macules and patches on his left forearm since birth, and the color became darker gradually. On physical examination, some well-defined, violaceous patches affected his left forearm that corresponded to C7 dermatome (A). There is no tender, itchy, or local heat associated with the skin lesions. The skin biopsy showed numerous ectatic, thin-walled blood vessels in the upper to middle dermis (B), consistent with PWS. Skin temperature and local microcirculatory blood perfusion were compared between the left and right sides of his forearms using laser Doppler perfusion measurement (PeriFlux System 5000; Perimed, Stockholm, Sweden), which determined the blood flow by measuring the number of red blood cells moving within the skin surface capillaries and the mean velocity of these cells. We used round probes (1cm in diameter) on the central area of his PWS lesions over the left forearm and the contralateral same site on his right forearm as the control skin. The skin temperature and blood perfusion over his lesional skin and control skin were similar. More specifically, the skin temperature on the patient’s PWS and the control site was 30.3°C and 30.2°C, respectively, and the blood perfusion [perfusion unit (PU)] on his lesional and normal skin was 10.1 and 10.4, respectively. Previous reports hypothesized that a lack of neural modulation of vascular tone may play a role in the etiology of PWS. For the assessment of autonomic dysfunction on the PWS skin, the method of cold recovery test was applied. Simultaneous application of ice-water packs (4°C) on the affected skin and the contralateral normal skin was maintained for 10 minutes, then cutaneous blood flow and skin temperature were recorded at an interval of 1 minute for a total 10 minutes following the removal of cold stress through laser Doppler perfusion measurement. No marked difference in skin temperature was noted between the lesional site and the control site from 1 to 10 minutes after ice packing removal (). On the other hand, there was a significant decrease in blood flow (from 10.4 to 6.7 PU) 1 minute after the removal of cold stress in the normal skin. However, no obvious change was observed in the lesional skin during the same period (). This finding suggested a certain degree of autonomic dysfunction in PWS skin, resulting in a defective capability of vasoconstriction. It is worthy to note that increases in blood flow were observed in both affected and control skin 5 minutes after the removal of ice packing (). This is because the body attempts to dilate the vessels in the superficial dermis to accelerate the surface temperature recovery. The etiology of PWS is unknown. Smoller and Rosen have demonstrated that perivascular innervation is decreased in PWS compared with the normal skin. They proposed that it may cause a lack of neural modulation of vascular tone, leading to progressive dilatation of vessels and could play a role in the development of PWS. Moreover, a significant reduction of the vasoactive response in PWS has been reported and suggests that there is a functional deficiency, further supporting this hypothesis. Body surface temperature regulation is activated during cold or heat stress through the alteration of local microcirculation, which is associated with various neurotransmitters. An autonomic dysregulation may result in different alterations of microcirculation in the time of cold stress on the affected skin; therefore, cold recovery test may be used to evaluate the potential sympathetic dysfunction of the skin, including segmental vitiligo, herpes zoster-affected dermatome, and diabetic neuropathy. Previous documents hypothesized that the etiology of PWS may be attributed to sympathetic dysfunction, so cold recovery test was chosen for the evaluation of our patient’s lesions, and an autonomic dysregulation was found. This suggested that, in addition to structural anomaly, functional dysregulation may also contribute to abnormal blood flow pattern in PWS after cold stress.