Foreign body reaction

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]

Table of Contents

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)

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

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