Tattoo-Induced Cutaneous Lymphoid Hyperplasia: A Case Series and Review of the Literature

Grazia Linda Artelli; Cesare Ariasi; Mariachiara Arisi; Annalisa Vascellaro; Benedetta Galli; Caterina Damiani; Giulio Gualdi; Simone Soglia; Marina Venturini; Piergiacomo Calzavara-Pinton; Patrycja Rogowska; Aneta Szczerkowska-Dobosz; Gaetano Licata

doi:10.5826/dpc.1602a6251

Tattoo-Induced Cutaneous Lymphoid Hyperplasia: A Case Series and Review of the Literature

Authors

Grazia Linda Artelli ASST Spedali Civili di Brescia
Cesare Ariasi Department of Dermatology, University of Brescia, Brescia, Italy
Mariachiara Arisi Department of Dermatology, University of Brescia, Brescia, Italy
Annalisa Vascellaro Department of Dermatology, University of Brescia, Brescia, Italy
Benedetta Galli Department of Dermatology, University of Brescia, Brescia, Italy
Caterina Damiani Department of Dermatology, University of Brescia, Brescia, Italy
Giulio Gualdi Clinic of Dermatology, Department of Medicine and Aging Sciences, University G. D'Annunzio, Chieti, Italy.
Simone Soglia Department of Dermatology, University of Brescia, Brescia, Italy
Marina Venturini Department of Dermatology, University of Brescia, Brescia, Italy
Piergiacomo Calzavara-Pinton Department of Dermatology, University of Brescia, Brescia, Italy
Patrycja Rogowska Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland.
Aneta Szczerkowska-Dobosz Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland.
Gaetano Licata Clinic of Dermatology, San Antonio Abate Hospital, Trapani, Italy

Keywords:

Cutaneous lymphoid hyperplasia, pseudolymphoma, Tattoo, Tattoo reaction, Red pigment

Abstract

Introduction: The increasing popularity of tattoos has been paralleled by a rise in tattoo-related skin reactions. Among these, tattoo-induced cutaneous lymphoid hyperplasia (CLH) remains a rare but increasingly recognized complication. Its pathogenesis and incidence are not yet fully understood, and diagnosis relies on histopathological confirmation via skin biopsy. Treatment approaches include topical or intralesional corticosteroids, surgical excision, and ablative CO₂ laser therapy in refractory cases.

Objectives: To analyze and describe the clinical and histopathological features of tattoo-induced CLH, including patient demographics, tattoo characteristics (e.g., location, ink color), latency periods, and lymphocyte predominance.

Methods: This study presents a case series of 15 patients with histologically-confirmed tattoo-induced CLH observed at dermatology departments in Brescia, Italy, and Gdańsk, Poland, between May 2017 and June 2023. These cases were integrated with a comprehensive literature review, resulting in a total of 58 patients analyzed. Data collected included patient demographics, tattoo location, latency period between tattooing and lesion onset, clinical features, ink color involved, lymphocyte predominance on histology, treatment modalities, and outcomes. The median patient age was 39 years, with an average latency of 33 months.

Results: Red ink was the most frequently implicated pigment. The predominant histopathological pattern was T-cell infiltration. Treatment responses varied. While topical and intralesional steroids showed inconsistent efficacy, surgical excision and ablative CO₂ laser treatments yielded the most favorable and sustained outcomes.

Conclusions: These findings underscore the importance of recognizing CLH as a delayed immune-mediated reaction, particularly to red pigments. Accurate diagnosis through biopsy is essential to distinguishing CLH from other tattoo-related dermatoses or cutaneous lymphomas, guiding appropriate management strategies.

References

Bălăceanu-Gurău B, Apostol E, Caraivan M, et al. Cutaneous Adverse Reactions Associated with Tattoos and Permanent Makeup Pigments. J Clin Med. 2024;13(2):503. DOI:10.3390/jcm13020503.

Gualdi G, Fabiano A, Moro R, et al. Tattoo: Ancient art and current problems. J Cosmet Dermatol. 2021;20(2):602-604. DOI:10.1111/jocd.13548.

Van Der Bent SAS, Rauwerdink D, Oyen EMM, Maijer KI, Rustemeyer T, Wolkerstorfer A. Complications of tattoos and permanent makeup: overview and analysis of 308 cases. J Cosmet Dermatol. 2021;20(11):3630-3641. DOI:10.1111/jocd.14498.

Rogowska P, Sobjanek M, Sławińska M, Nowicki RJ, Szczerkowska-Dobosz A. Tattoos Dermatological Complications: Analysis of 53 Cases from Northern Poland. Dermatol Basel Switz. 2022;238(4):799-806. DOI:10.1159/000520752.

Marchesi A, Parodi PC, Brioschi M, et al. Tattoo Ink-Related Cutaneous Pseudolymphoma: A Rare but Significant Complication. Case Report and Review of the Literature. Aesthetic Plast Surg. 2014;38(2):471-478. DOI:10.1007/s00266-014-0287-5.

Pasolini G, Ghidini P, Arisi M, Pedretti A, Ungari M, Pinton PC. Pseudolymphoma tattoo-induced. Dermatol Rep. 2011;3(3):e47. DOI:10.4081/dr.2011.e47.

Gardair Bouchy C, Kerdraon R, Kluger N, Armingaud P, Wakosa A, Estève E. [Cutaneous lymphoid hyperplasia (pseudolymphoma) on the red dye of a tattoo]. Ann Pathol. 2013;33(4):273-277. DOI:10.1016/j.annpat.2013.04.005.

Kluger N, Vermeulen C, Moguelet P, et al. Cutaneous lymphoid hyperplasia (pseudolymphoma) in tattoos: a case series of seven patients. J Eur Acad Dermatol Venereol JEADV. 2010;24(2):208-213. DOI:10.1111/j.1468-3083.2009.03305.x.

Zengarini C, Ferrari T, Orioni G, et al. Cutaneous pseudolymphoma related to violet tattoo ink successfully treated with intralesional corticosteroid. Ital J Dermatol Venereol. 2022;157(3):290-291. DOI:10.23736/S2784-8671.21.07064-X.

Navarro-Triviño FJ, Naranjo-Diaz MJ, Ruiz-Villaverde R. Cutaneous lymphoid hyperplasia caused by cosmetic lip tattoo successfully treated with tacrolimus 0.1% ointment. Contact Dermatitis. 2021;84(4):270-272. DOI:10.1111/cod.13726.

Moulonguet I, Garçon N, Rivet J, Cavelier-Balloy B. Nodule developing over a tattoo: challenge. Cutaneous lymphoid hyperplasia (pseudolymphoma). Am J Dermatopathol. 2014;36(1):88-89, 101-102. DOI:10.1097/DAD.0b013e3182957a11

Cristaudo A, Forte G, Bocca B, et al. Permanent tattoos: evidence of pseudolymphoma in three patients and metal composition of the dyes. Eur J Dermatol EJD. 2012;22(6):776-780. DOI:10.1684/ejd.2012.1844.

Tan LS, Oon HH, Lee JSS, Chua SH. Successful Treatment of Tattoo-Induced Pseudolymphoma with Sequential Ablative Fractional Resurfacing Followed by Q-Switched Nd: YAG 532 nm Laser. J Cutan Aesthetic Surg. 2013;6(4):226-228. DOI:10.4103/0974-2077.123412.

Chiang C, Romero L. Cutaneous lymphoid hyperplasia (pseudolymphoma) in a tattoo after far infrared light. Dermatol Surg Off Publ Am Soc Dermatol Surg Al. 2009;35(9):1434-1438. DOI:10.1111/j.1524-4725.2009.01254.x.

Gutermuth J, Hein R, Fend F, Ring J, Jakob T. Cutaneous pseudolymphoma arising after tattoo placement. J Eur Acad Dermatol Venereol JEADV. 2007;21(4):566-567. DOI:10.1111/j.1468-3083.2006.01964.x.

Muñoz C, Guilabert A, Mascaró JM, Lopez-Lerma I, Vilaplana J. An embossed tattoo. Clin Exp Dermatol. 2006;31(2):309-310. DOI:10.1111/j.1365-2230.2005.01956.x.

Cruz FAM, Lage D, Frigério RM, Zaniboni MC, Arruda LHF. Reactions to the different pigments in tattoos: a report of two cases. An Bras Dermatol. 2010;85(5):708-711. DOI:10.1590/s0365-05962010000500019.

Shin JB, Seo SH, Kim BK, Kim IH, Son SW. Cutaneous T cell pseudolymphoma at the site of a semipermanent lip-liner tattoo. Dermatol Basel Switz. 2009;218(1):75-78. DOI:10.1159/000174102.

Kahofer P, El Shabrawi-Caelen L, Horn M, Kern T, Smolle J. Pseudolymphoma occurring in a tattoo. Eur J Dermatol EJD. 2003;13(2):209-212.

Blumental G, Okun MR, Ponitch JA. Pseudolymphomatous reaction to tattoos. Report of three cases. J Am Acad Dermatol. 1982;6(4 Pt 1):485-488. DOI:10.1016/s0190-9622(82)70041-6.

Zinberg M, Heilman E, Glickman F. Cutaneous pseudolymphoma resulting from a tattoo. J Dermatol Surg Oncol. 1982;8(11):955-958. DOI:10.1111/j.1524-4725.1982.tb01075.x.

Chave TA, Mortimer NJ, Johnston GA. Simultaneous pseudolymphomatous and lichenoid tattoo reactions triggered by re-tattooing. Clin Exp Dermatol. 2004;29(2):197-199. DOI:10.1111/j.1365-2230.2004.01459.x.

Patrizi A, Raone B, Savoia F, et al. Tattoo-associated pseudolymphomatous reaction and its successful treatment with hydroxychloroquine. Acta Derm Venereol. 2009;89(3):327-328. DOI:10.2340/00015555-0639.

Amann U, Luger TA, Metze D. [Lichenoid pseudolymphomatous tattooing reaction]. Hautarzt Z Dermatol Venerol Verwandte Geb. 1997;48(6):410-413. DOI:10.1007/s001050050603.

Sangueza OP, Yadav S, White CR, Braziel RM. Evolution of B-cell lymphoma from pseudolymphoma. A multidisciplinary approach using histology, immunohistochemistry, and Southern blot analysis. Am J Dermatopathol. 1992;14(5):408-413. DOI:10.1097/00000372-199210000-00006.

Nilles M, Eckert F. [Pseudolymphoma following tattooing]. Hautarzt Z Dermatol Venerol Verwandte Geb. 1990;41(4):236-238.

Mayerhausen W, Ehlers G. [Pseudolymphoma following cosmetic tattooing]. Hautarzt Z Dermatol Venerol Verwandte Geb. 1986;37(11):622-624.

Rijlaarsdam JU, Bruynzeel DP, Vos W, Meijer CJ, Willemze R. Immunohistochemical studies of lymphadenosis benigna cutis occurring in a tattoo. Am J Dermatopathol. 1988;10(6):518-523. DOI:10.1097/00000372-198812000-00008.

Lubach D, Hinz E. [A pseudolymphomatous reaction in tattooing]. Hautarzt Z Dermatol Venerol Verwandte Geb. 1986;37(10):573-575.

Malki S, Onnis G, Lissia A, Montesu MA, Satta R. Cutaneous T pseudolymphoma on the red pigmented areas of a tattoo. Int J Dermatol. 2017;56(8):e172-e173. DOI:10.1111/ijd.13659.

Camilot D, Arnez ZM, Luzar B, Pizem J, Zgavec B, Falconieri G. Cutaneous pseudolymphoma following tattoo application: report of two new cases of a potential lymphoma mimicker. Int J Surg Pathol. 2012;20(3):311-315. DOI:10.1177/1066896911425487.

Mendez Diaz Y, García-Arpa M, Parra Cubillos A, De Lara Simón IM, García Rodriguez R, Gómez Torrijos E. Cutaneous Pseudolymphoma Secondary to Exogenous Pigment in a Polychrome Tattoo. J Investig Allergol Clin Immunol. 2018;28(3):199-201. DOI:10.18176/jiaci.0238.

Souza ES, Rocha B de O, Batista E da S, Oliveira RF de, Farre L, Bittencourt AL. T-cell-predominant lymphoid hyperplasia in a tattoo. An Bras Dermatol. 2014;89(6):1019-1021. DOI:10.1590/abd1806-4841.20143231.

Haus G, Utikal J, Geraud C, Goerdt S, Leverkus M. CD30-positive lymphoproliferative disorder in a red tattoo: regional lymphomatoid papulosis type C or pseudolymphoma? Br J Dermatol. 2014;171(3):668-670. DOI:10.1111/bjd.13024.

Campolmi P, Bassi A, Bonan P, et al. Cutaneous pseudolymphoma localized to black tattoo. J Am Acad Dermatol. 2011;65(5):e155-157. DOI:10.1016/j.jaad.2011.06.039.

Torabian S, Fung M, Lamb P. Pseudolymphoma occurring in a tattoo. J Am Acad Dermatol. 2007;56(2):AB142. DOI:10.1016/j.jaad.2006.10.661.

Islam PS, Chang C, Selmi C, et al. Medical Complications of Tattoos: A Comprehensive Review. Clin Rev Allergy Immunol. 2016;50(2):273-286. DOI:10.1007/s12016-016-8532-0.

Serup J, Hutton Carlsen K, Sepehri M. Tattoo Complaints and Complications: Diagnosis and Clinical Spectrum. In: Serup J, Kluger N, Bäumler W, eds. Current Problems in Dermatology. Vol 48. S. Karger AG; 2015:48-60. DOI:10.1159/000369645.

Stingeni L, Bianchi L, Hansel K, et al. Italian Guidelines in Patch Testing - adapted from the European Society of Contact Dermatitis (ESCD). G Ital Dermatol E Venereol Organo Uff Soc Ital Dermatol E Sifilogr. 2019;154(3):227-253. DOI:10.23736/S0392-0488.19.06301-6.

Ariasi C, Licata G, Perazzolli G, et al. Features of tattoo-associated cutaneous lymphoid hyperplasia on reflectance confocal microscopy and line-field confocal optical coherence tomography. Australas J Dermatol. Published online March 4, 2024. DOI:10.1111/ajd.14246.

Soglia S, Pérez-Anker J, Ghini I, et al. Line-field confocal optical coherence tomography: A new in vivo assessment tool for cutaneous mycosis fungoides. J Eur Acad Dermatol Venereol JEADV. 2024;38(3):e296-e298. DOI:10.1111/jdv.19633.

Bäumler W. Chemical hazard of tattoo colorants. Presse Medicale Paris Fr 1983. 2020;49(4):104046. DOI:10.1016/j.lpm.2020.104046.

Schreiver I, Hesse B, Seim C, et al. Distribution of nickel and chromium containing particles from tattoo needle wear in humans and its possible impact on allergic reactions. Part Fibre Toxicol. 2019;16(1):33. DOI:10.1186/s12989-019-0317-1.

Schubert S, Kluger N, Schreiver I. Hypersensitivity to permanent tattoos: Literature summary and comprehensive review of patch tested tattoo patients 1997–2022. Contact Dermatitis. 2023;88(5):331-350. DOI:10.1111/cod.14291.

Hutton Carlsen K, Serup J. Photosensitivity and photodynamic events in black, red and blue tattoos are common: A ‘Beach Study.’ J Eur Acad Dermatol Venereol. 2014;28(2):231-237. DOI:10.1111/jdv.12093.

Van Der Bent S, Oyen E, Rustemeyer T, Jaspars L, Hoekzema R. Histopathology of Red Tattoo Reactions. Am J Dermatopathol. 2021;43(5):331-337. DOI:10.1097/DAD.0000000000001751.

Bil W, van der Bent SAS, Spiekstra SW, Nazmi K, Rustemeyer T, Gibbs S. Comparison of the skin sensitization potential of 3 red and 2 black tattoo inks using interleukin-18 as a biomarker in a reconstructed human skin model. Contact Dermatitis. 2018;79(6):336-345. DOI:10.1111/cod.13092.

Serup J, Hutton Carlsen K, Dommershausen N, et al. Identification of pigments related to allergic tattoo reactions in 104 human skin biopsies. Contact Dermatitis. 2020;82(2):73-82. DOI:10.1111/cod.13423.

Serup J, Hutton Carlsen K. Patch test study of 90 patients with tattoo reactions: negative outcome of allergy patch test to baseline batteries and culprit inks suggests allergen(s) are generated in the skin through haptenization. Contact Dermatitis. 2014;71(5):255-263. DOI:10.1111/cod.12271.

van der Bent S a. S, de Winter RW, Wolkerstorfer A, Rustemeyer T. Red tattoo reactions, a prospective cohort on clinical aspects. J Eur Acad Dermatol Venereol JEADV. 2019;33(10):e384-e386. DOI:10.1111/jdv.15677.

Liszewski W, Warshaw EM. Pigments in American tattoo inks and their propensity to elicit allergic contact dermatitis. J Am Acad Dermatol. 2019;81(2):379-385. DOI:10.1016/j.jaad.2019.01.078.

Bourgeois P, Roman MM, Schweicher J, et al. Lymphatic Alterations Under Tattoos: Preliminary Reports of One Observational Study. Clin Cosmet Investig Dermatol. 2023;16:257-265. DOI:10.2147/CCID.S393038.

Kluger N. Pseudolymphoma on tattoos. Aesthetic Plast Surg. 2014;38(5):1068-1069. DOI:10.1007/s00266-014-0349-8.

King BJ, Lehman JS, Macon WR, Sciallis GF. Red tattoo-related mycosis fungoides-like CD8+ pseudolymphoma. J Cutan Pathol. 2018;45(3):226-228. DOI:10.1111/cup.13089.

Kluger N, Mitcov M, Mahé A. Primary cutaneous marginal zone B-cell lymphoma in an old tattoo. Ann Dermatol Venereol. 2024;151(3):103293. DOI:10.1016/j.annder.2024.103293.

Kluger N, Jeskanen L, Cajanus S, Lappalainen K. Primary cutaneous follicle center lymphoma within a tattoo. Ann Dermatol Venereol. 2022;149(4):281-283. DOI:10.1016/j.annder.2022.03.004.

Clemmensen SB, Mengel-From J, Kaprio J, Frederiksen H, Von Bornemann Hjelmborg J. Tattoo ink exposure is associated with lymphoma and skin cancers – a Danish study of twins. BMC Public Health. 2025;25(1):170. DOI:10.1186/s12889-025-21413-3.

Nielsen C, Jerkeman M, Jöud AS. Tattoos as a risk factor for malignant lymphoma: a population-based case–control study. eClinicalMedicine. 2024;72:102649. DOI:10.1016/j.eclinm.2024.102649.

Kluger N. A recent study on tattoos and lymphoma does not support a possible association. Ann Dermatol Venereol. 2024;151(4):103320. DOI:10.1016/j.annder.2024.103320.

Hibler BP, Rossi AM. A case of delayed anaphylaxis after laser tattoo removal. JAAD Case Rep. 2015;1(2):80-81. DOI:10.1016/j.jdcr.2015.01.005.