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Skin inflammatory (nontumor)
Dermal granulomatous and necrobiotic reaction patterns
Foreign body reaction
Copyright: 2002-2019, PathologyOutlines.com, Inc.
PubMed Search: Foreign body reaction [title]
Dermal granulomatous and necrobiotic reaction patterns
Foreign body reaction
Author: Ifeoma U. Perkins, M.D.
Senior Authors: Jerad M. Gardner, M.D., Lauren N. Stuart, M.D., M.B.A.
Topic Completed: 1 June 2015
Revised: 27 March 2019
Copyright: 2002-2019, PathologyOutlines.com, Inc.
PubMed Search: Foreign body reaction [title]
Table of Contents
Definition / general | Terminology | Epidemiology | Sites | Pathophysiology | Clinical features | Radiology description | Case reports | Treatment | Microscopic (histologic) description | Microscopic (histologic) images | Positive stainsCite this page: Perkins IU Foreign body reaction. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/skinnontumorforeignbodyreaction.html. Accessed September 23rd, 2019.
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
- Granuloma: organized collection of macrophages or histiocytes, usually arising in response to an infectious pathogen or foreign or unknown substance
- Foreign body: any exogenous substance not inherently native to the body (e.g. suture material) or foreign to a specific body part (e.g. urate crystals in the skin) (Mosby: Mosby's Medical Dictionary, 8th Edition, 2008, Bolognia: 2-Volume Set: Expert Consult Premium Edition, 3rd Edition, 2012)
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
- 43 year old woman with foreign body granuloma due to Matridex injection for cosmetic purposes (Am J Dermatopathol 2009;31:197)
- 45 year old man with cutaneous silica granuloma with generalized involvement of lymph nodes (J Dermatol 2011;38:697)
- Cutaneous mercury deposits after henna dye application in arm (Br J Dermatol 2007;157:394)
Treatment
- Complete excision with removal of offending agent is often curative
- Superinfected lesions may require antimicrobial therapy (Dermatol Online J 2013;19:19261, Dermatol Surg 2009;35:1672)
Microscopic (histologic) 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
Microscopic (histologic) images
Images hosted on other servers:
Silica granuloma
Multinucleated giant cells engulfing suture
Postsurgical due to suture material
Due to wooden splinters
Due to tattoo pigment
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