Tattoo-Associated Cutaneous Sarcoidosis: A Literature Review and Clinical Case Reports

Tattoos and permanent makeup are increasingly common in the general population, accompanied by a growing number of adverse events related to pigment implantation into the skin. Granulomatous reactions and tattoo-associated sarcoidosis are of particular interest because they may reflect not only a local inflammatory response but also systemic involvement. Despite the increasing number of publications on this topic, many aspects of the pathogenesis, diagnosis, and differential diagnosis of cutaneous sarcoidosis arising in tattooed skin remain insufficiently understood. The aim of this study was to review current evidence on tattoo-associated cutaneous sarcoidosis and to present two clinical cases of patients with papulonodular lesions developing in areas of pigment implantation. A total of 62 publications addressing the epidemiology, pathogenesis, clinical manifestations, and diagnosis of tattoo-associated sarcoidosis were analyzed. The review summarizes current knowledge regarding the potential role of tattoo pigments in the development of granulomatous inflammation, the clinical features of localized and systemic forms of sarcoidosis, and contemporary approaches to the differential diagnosis of sarcoidosis and sarcoid-like reactions induced by exogenous antigens. Particular attention is paid to the risk of systemic involvement in patients presenting with papulonodular lesions within tattoos and to the diagnostic value of comprehensive clinical, dermoscopic, and histopathological evaluation. The available evidence suggests that granulomatous lesions arising in tattooed skin may represent the first manifestation of systemic sarcoidosis and therefore require a multidisciplinary diagnostic approach. The presented cases and literature data provide additional insight into the clinical, dermoscopic, and histopathological features of tattoo-associated cutaneous sarcoidosis and highlight the ongoing challenges in distinguishing true cutaneous sarcoidosis from sarcoid-like reactions to tattoo pigments.