Tattoos as a risk factor for malignant lymphoma: a population-based case-control study

Abstract

Background: The popularity of tattoos has increased dramatically over the last few decades. Tattoo ink often contains carcinogenic chemicals, e.g., primary aromatic amines, polycyclic aromatic hydrocarbons, and metals. The tattooing process invokes an immunologic response that causes translocation of tattoo ink from the injection site. Deposition of tattoo pigment in lymph nodes has been confirmed but the long-term health effects remain unexplored. We used Swedish National Authority Registers with full population coverage to investigate the association between tattoo exposure and overall malignant lymphoma as well as lymphoma subtypes.

Methods: We performed a case-control study where we identified all incident cases of malignant lymphoma diagnosed between 2007 and 2017 in individuals aged 20-60 years in the Swedish National Cancer Register. Three random age- and sex-matched controls per case were sampled from the Total Population Register using incidence density sampling. We assessed exposure through a questionnaire in 2021, and data on potential confounders were retrieved from registers. We used multivariable logistic regression to estimate the incidence rate ratio (IRR) of malignant lymphoma in tattooed individuals.

Findings: The study population consisted of 11,905 individuals, and the response rate was 54% among cases (n = 1398) and 47% among controls (n = 4193). The tattoo prevalence was 21% among cases and 18% among controls. Tattooed individuals had a higher adjusted risk of overall lymphoma (IRR = 1.21; 95% CI 0.99-1.48). The risk of lymphoma was highest in individuals with less than two years between their first tattoo and the index year (IRR = 1.81; 95% CI 1.03-3.20). The risk decreased with intermediate exposure duration (three to ten years) but increased again in individuals who received their first tattoo ≥11 years before the index year (IRR = 1.19; 95% CI 0.94-1.50). We found no evidence of increasing risk with a larger area of total tattooed body surface. The risk associated with tattoo exposure seemed to be highest for diffuse large B-cell lymphoma (IRR 1.30; 95% CI 0.99-1.71) and follicular lymphoma (IRR 1.29; 95% CI 0.92-1.82).

Interpretation: Our findings suggested that tattoo exposure was associated with an increased risk of malignant lymphoma. More epidemiologic research is urgently needed to establish causality.

Funding: The Swedish Research Council for Health, Working Life and Welfare.

Keywords: Cancer; Cancer prevention; Lifestyle-related risk factor; Lymphoma; Population-based research.

Fig. 1

Flowchart describing the inclusion of study participants.

Fig. 2

Adjusted incidence rate ratios (IRR) of malignant lymphoma subtypes in tattooed relative to nontattooed participants. The error bars represent the upper and lower limits of the 95th confidence intervals of the estimates. Tattoo exposure was modelled as a) exposure status (yes; no), and b) exposure duration (years). The underlying numeric data for this figure are presented inTable S3. DLBCL, diffuse large B-cell lymphoma.