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

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.