A 20-year-old man in China developed a severe necrotic ulcer at the site of a red cross tattoo on his neck, according to a recently reported medical case published in JAMA Otolaryngology–Head & Neck Surgery.1 The condition emerged months after the tattoo was inked, when the design began to fade and was replaced by progressive skin damage. The case has drawn attention due to its unusual presentation and rare severity.
The man had received the tattoo at the base of his neck. About three months later, the red pigment started to disappear without any external intervention. As the tattoo faded, the affected area developed scarring, swelling, and eventually an ulcer with dead tissue.
Over the following weeks, the lesion expanded and became more severe. By the fifth month after getting the tattoo, the patient sought medical help due to worsening symptoms and visible tissue damage.
Reports noted that the fading of the tattoo coincided directly with the onset of tissue destruction, an unusual sequence that raised suspicion of an underlying pathological process rather than a simple cosmetic fading.
On examination, doctors identified enlarged and hardened lymph nodes in the neck region. Imaging studies, including CT and MRI scans, revealed soft tissue masses and blood clots in both jugular veins.
Initial treatment with antibiotics and topical steroids did not lead to improvement. To identify the cause, clinicians performed biopsies of the affected tissue. Microscopic examination showed tissue necrosis, inflammatory cell infiltration, and fibrosis. However, no infectious organism was detected.
Further testing ruled out infections such as tuberculosis and Epstein-Barr virus, which are commonly associated with similar lymph node changes.
Additional reports emphasized that despite extensive testing, no bacterial, viral, or fungal cause could be identified, strengthening the likelihood of a non-infectious inflammatory or immune-mediated process.
Based on clinical and laboratory findings, doctors diagnosed the patient with necrotizing granulomatous lymphadenitis.1
This condition involves inflammation of lymph nodes along with tissue destruction and formation of granulomas, which are clusters of immune cells formed in response to persistent irritation or foreign substances.1
Although the exact trigger could not be confirmed, clinicians suggested that the tattoo ink may have provoked a delayed immune reaction. Red tattoo pigments are known to contain compounds that can sometimes activate the immune system.
According to Live Science, red tattoo pigments are among the most commonly implicated in delayed hypersensitivity reactions, often linked to metal-based compounds such as mercury sulfide or azo dyes.
Doctors proposed several mechanisms that may have contributed to the progression of the disease. These include a persistent immune response to tattoo pigment, inflammation-induced damage to surrounding tissues, and compression of blood vessels by swollen lymph nodes. Reduced blood flow in the affected region may have led to tissue death and ulcer formation.
Reports like also suggested that vascular involvement, including thrombosis of the jugular veins, may have further compromised blood supply, accelerating tissue necrosis and worsening the ulcerative process.
Due to the severity and progression of the lesion, surgical intervention was required. Doctors removed the necrotic tissue along with surrounding affected structures. The procedure also included ligation of both jugular veins to manage the associated blood clots.
Reconstruction of the neck area was carried out using tissue grafted from the patient’s thigh. Postoperative care included short-term hormone therapy to control inflammation. The patient recovered following treatment.
Case reports indicate that aggressive surgical management was necessary due to the rapid progression and failure of conservative therapy, highlighting the potential severity of such rare reactions.
This case represents a rare complication linked to tattooing. The authors stated that “this report expands the spectrum of tattoo-associated pathology.” However, since this is only the second documented case, the condition appears to be extremely rare.
Most tattoo-related reactions are mild and limited to local inflammation or allergic responses. However, this report highlights that in uncommon situations, severe tissue damage can occur.
The absence of detectable tattoo pigment in the affected tissue limited further analysis, leaving the exact cause uncertain. Nonetheless, the case underscores the importance of recognizing unusual skin changes following tattoo procedures and seeking timely medical evaluation.
The complete disappearance of pigment alongside tissue destruction is highly unusual, suggesting that immune-mediated clearance of the pigment may have occurred simultaneously with tissue injury
1. Yang, L., and W. Li. “A Young Adult With Aggressive Lesions in the Neck.” JAMA Otolaryngology–Head & Neck Surgery 151, no. 9 (2025): 898–899. https://doi.org/10.1001/jamaoto.2025.2079.
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