Lactylation, a post-translational modification, has been linked to gene transcription regulation through epigenetic modulation in various pathophysiological processes. The lactylation regulatory proteins, known as writers, erasers, and readers, govern their dynamics by adding, removing, and recognizing lactyl groups on proteins. Macrophages, as cells of the immune system, maintain homeostasis, responding dynamically to diverse internal and external stimuli. Emerging researches unveil that lactylation, through inducing macrophage activation and polarization, affects their functionality in pathological conditions such as inflammation, tumor microenvironment, and fibrosis. Evidence progressively indicates that lactate-driven alterations in lactylation levels within macrophages can influence the pathogenesis of numerous diseases. This review aims to systematically summarize the research progress of lactylation in macrophages, explore its functions and mechanisms by which lactylation contributes to the pathology of different disease phenotypes, and propose future research directions along with potential diagnostic and therapeutic strategies.