Skin-nontumor / Clinical dermatology
Granulomatous but non-infectious disorders
Foreign body reaction

Author: Ifeoma Nwadei, M.D. (see Authors page)
Editors: Jerad Gardner, M.D. and Lauren Stuart, M.D.

Revised: 2 June 2016, last major update June 2015

Copyright: (c) 2002-2016, PathologyOutlines.com, Inc.

PubMed Search: Foreign body reaction [title]

Cite this page: Foreign body reaction. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/skinnontumorforeignbodyreaction.html. Accessed December 4th, 2016.
Definition / General
  • Granulomatous inflammatory changes due to the presence of foreign / exogenous material
  • Offending agents may be grouped as follows:
    • Iatrogenic: talc, suture, surgical adhesive, injectable prescription drugs
    • Cosmetic: silicon, lipid, zirconium, cutaneous bleaching agents, bovine collagen, injectable fillers including hyaluronic acid and many others
    • Traumatic: metallic or non metallic splinters, shrapnel, arthropod bite / mouth parts, sea urchin spine, cactus glochids / spines, hair or keratin from ruptured cysts or follicles
    • Occupational: beryllium, silver, silica, hair (groomers or hair dressers / barbers)
    • Self inflicted: tattoos, mercury, injected recreational drugs, food particles, injected mineral oil or paraffin (for attempted cosmesis) (Clin Dermatol 1991;9:157, Am J Dermatopathol 2014;36:409, Dermatology 2014;228:14, Facial Plast Surg 2014;30:615)
Terminology
Epidemiology
  • Varies widely depending on type of foreign material
Sites
  • Most commonly presents at site(s) of initial cutaneous injury
  • Rare "migratory" granulomas are due to visible dermatologic lesions remote from initial site of injury (Ann Diagn Pathol 2015;19:10)
Pathophysiology
  • Exogenous material enters skin via disruption of epidermis (e.g. penetrating injury, injection, surgical manipulation, etc.)
  • Exogenous material is recognized as foreign by antigen presenting cells (tissue macrophages), which surround the material to quarantine it from surrounding uninvolved tissue
Clinical Features
  • Variable including localized erythema, induration, pigment alteration, nodules / papules at site(s) of cutaneous injury
  • Over time, lesions may become ulcerated and colonized secondarily by bacteria
  • Deep fungal or bacterial infection and abscess may develop if foreign material was contaminated with fungal organisms (e.g. wood splinters)
  • Lesion may heal only to later become painful and ulcerate with extrusion of foreign material (e.g. transepidermal elimination of suture material long after surgery)
  • Foreign material may migrate via lymphatics to regional lymph nodes, leading to nodal granulomas and palpable lymphadenopathy
Radiology Description
  • Utility is based upon features of foreign body (e.g. composition, size, orientation, duration of its presence) and anatomic site
  • Plain radiographs (Xrays) may visualize metallic substances more readily than non metallic agents
  • Ultrasonography may be useful to visualize and remove lesions in extremities
  • Computed tomography (CT) and magnetic resonance (MR) are less readily available and more costly; MR may be dangerous if foreign material is metallic and magnetic (J Emerg Med 2014;47:e43, J Eur Acad Dermatol Venereol 2012;26:292)
Case Reports
Treatment
Micro Description
  • Well formed, often non caseating granulomas consisting of histiocytes, usually epithelioid with central foreign body
  • Granulomas are surrounded by variable amounts of lymphocyte predominant chronic inflammation and reactive dermal fibrosis
  • Foreign body is often refractile but may or may not be polarizable; examination with polarized light is useful component of granulomatous dermatitis workup
  • PAS and GMS stains may be useful to rule out secondary deep fungal infection
Micro Images

Images hosted on other servers:

Foreign material engulfed and surrounded by granuloma



Silica granuloma

Multinucleated giant cells engulfing suture

Post-surgical due to suture material

Due to wooden splinters

Due to tattoo pigment

Positive Stains
  • CD68: stains multinucleated giant cells
  • PAS-D, GMS and AFB: may be positive for microorganisms in infected granulomas