Hard, Pink Nodules on the Upper Extremities —Diagnosis
Hard, Pink Nodules on the Upper Extremities —Diagnosis
2011-10-01 00:00:00
Diagnosis: Peripheral siliconomas. Microscopic findings A biopsy specimen showed granulomatous inflammation with multinucleated giant cells and variably sized vacuoles, giving a “Swiss cheese ” appearance in the dermis, consistent with cutaneous silicone deposition with foreign body reaction. No polarizable material was present. Discussion The term siliconoma was first used to describe the local response to the liquid silicone injection technique that had been developed for breast augmentation in the 1950s. The first case of siliconomas was reported in1964.1 Because these lesions are both painful and disfiguring, the recommended treatment is local excision.2 The first peripheral siliconomas were described in the 1980s. They usually appeared as granulomas on the chest and abdomen after silent leakage of a silicone breast implant,3 typically with a latency period of decades after the leak began. There are rare reports of siliconomas at distant sites, such as arms, axillae, and legs. The route of systemic migration remains unclear.3,4 The presentation of siliconomas can be incredibly variable, ranging from slightly erythematous to skin-colored papules, as in the present case, to diffuse swelling and erythema, to lymphadenopathy.2 Histologically, the differential diagnosis includes other granulomatous reactions, including sarcoidosis, tuberculosis, and foreign body granulomas of various origin, such as paraffinomas. Both paraffinomas and siliconomas have a “Swiss cheese ” appearance, with granuloma formation and collagen fibrosis. Neither material is refractile under polarized light. The distinction is often made primarily by clinical history, as in this case. If the history is not clear, fat staining can be performed for further workup, with paraffinoma staining positive and siliconoma negative in the setting of alcohol fixation. Clinically, lupus profundus, pseudolymphoma, and factitial panniculitis can be included in the list of differential diagnoses.2,5 Excision remains the most definitive treatment option for peripheral siliconomas, but this procedure is not feasible in all areas and sometimes has a poor cosmetic outcome. In areas that are not amenable to surgical excision, options include intralesional or systemic corticosteroid therapy, but patients often experience a flare on tapering. The use of oral retinoids, specifically low-dose isotretinoin at 20 mg/d, has been described as successful over a period of 6 months.6 Reduction in size and number has also been reported with a course of minocycline (100 mg/d). Significant size reduction has been observed in as few as 4 weeks, with near-complete resolution after 1 year.2 Our patient declined further treatment and has been unavailable for follow-up. Return to Quiz Case. Submissions Clinicians, local and regional societies, and residents and fellows in dermatology are invited to submit quiz cases to this section. Cases should follow the established pattern of a Report of a Case section of less than 150 words, followed by the Diagnosis, Microscopic Findings, and Discussion. The discussion should be between 285 and 350 words. References are limited to 9. The text should be submitted double-spaced, with the right margin ragged. Photomicrographs and illustrations must be wider than they are tall (horizontal orientation), sharply focused with good color balance, and submitted as separate JPG files with each file numbered with the figure number. Material must be accompanied by the required copyright transfer statement (see authorship form in Instructions for Authors [http://archderm.ama-assn.org/misc/auinst_crit.pdf]). Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archdermatol.com). Please indicate in your cover letter that the manuscript is a submission to Off-Center Fold. References 1. Winer LH, Sternberg TH, Lehman R, Ashley FL. Tissue reactions to injected silicone liquids: a report of three cases. Arch Dermatol. 1964;90:588-59314206865PubMedGoogle ScholarCrossref 2. Arin MJ, B äte J, Krieg T, Hunzelmann N. Silicone granuloma of the face treated with minocycline. J Am Acad Dermatol. 2005;52(2):(suppl 1) 53-5615692516PubMedGoogle ScholarCrossref 3. Sagi L, Baum S, Lyakhovitsky A, et al. Silicone breast implant rupture presenting as bilateral leg nodules. Clin Exp Dermatol. 2009;34(5):e99-e10119438562PubMedGoogle ScholarCrossref 4. Dragu A, Theegarten D, Bach AD, et al. Intrapulmonary and cutaneous siliconomas after silent silicone breast implant failure. Breast J. 2009;15(5):496-49919624416PubMedGoogle ScholarCrossref 5. Mason J, Apisarnthanarax P. Migratory silicone granuloma. Arch Dermatol. 1981;117(6):366-3677018405PubMedGoogle ScholarCrossref 6. Jansen T, Kossmann E, Plewig G. Siliconoma: an interdisciplinary problem. Hautarzt. 1993;44(10):636-6438225972PubMedGoogle Scholar
http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.pngArchives of DermatologyAmerican Medical Associationhttp://www.deepdyve.com/lp/american-medical-association/hard-pink-nodules-on-the-upper-extremities-diagnosis-dpu2Jf3CaK
Hard, Pink Nodules on the Upper Extremities —Diagnosis
Hard, Pink Nodules on the Upper Extremities —Diagnosis
Abstract
Diagnosis: Peripheral siliconomas. Microscopic findings A biopsy specimen showed granulomatous inflammation with multinucleated giant cells and variably sized vacuoles, giving a “Swiss cheese ” appearance in the dermis, consistent with cutaneous silicone deposition with foreign body reaction. No polarizable material was present. Discussion The term siliconoma was first used to describe the local response to the liquid silicone injection technique that had been developed for breast...
Diagnosis: Peripheral siliconomas. Microscopic findings A biopsy specimen showed granulomatous inflammation with multinucleated giant cells and variably sized vacuoles, giving a “Swiss cheese ” appearance in the dermis, consistent with cutaneous silicone deposition with foreign body reaction. No polarizable material was present. Discussion The term siliconoma was first used to describe the local response to the liquid silicone injection technique that had been developed for breast augmentation in the 1950s. The first case of siliconomas was reported in1964.1 Because these lesions are both painful and disfiguring, the recommended treatment is local excision.2 The first peripheral siliconomas were described in the 1980s. They usually appeared as granulomas on the chest and abdomen after silent leakage of a silicone breast implant,3 typically with a latency period of decades after the leak began. There are rare reports of siliconomas at distant sites, such as arms, axillae, and legs. The route of systemic migration remains unclear.3,4 The presentation of siliconomas can be incredibly variable, ranging from slightly erythematous to skin-colored papules, as in the present case, to diffuse swelling and erythema, to lymphadenopathy.2 Histologically, the differential diagnosis includes other granulomatous reactions, including sarcoidosis, tuberculosis, and foreign body granulomas of various origin, such as paraffinomas. Both paraffinomas and siliconomas have a “Swiss cheese ” appearance, with granuloma formation and collagen fibrosis. Neither material is refractile under polarized light. The distinction is often made primarily by clinical history, as in this case. If the history is not clear, fat staining can be performed for further workup, with paraffinoma staining positive and siliconoma negative in the setting of alcohol fixation. Clinically, lupus profundus, pseudolymphoma, and factitial panniculitis can be included in the list of differential diagnoses.2,5 Excision remains the most definitive treatment option for peripheral siliconomas, but this procedure is not feasible in all areas and sometimes has a poor cosmetic outcome. In areas that are not amenable to surgical excision, options include intralesional or systemic corticosteroid therapy, but patients often experience a flare on tapering. The use of oral retinoids, specifically low-dose isotretinoin at 20 mg/d, has been described as successful over a period of 6 months.6 Reduction in size and number has also been reported with a course of minocycline (100 mg/d). Significant size reduction has been observed in as few as 4 weeks, with near-complete resolution after 1 year.2 Our patient declined further treatment and has been unavailable for follow-up. Return to Quiz Case. Submissions Clinicians, local and regional societies, and residents and fellows in dermatology are invited to submit quiz cases to this section. Cases should follow the established pattern of a Report of a Case section of less than 150 words, followed by the Diagnosis, Microscopic Findings, and Discussion. The discussion should be between 285 and 350 words. References are limited to 9. The text should be submitted double-spaced, with the right margin ragged. Photomicrographs and illustrations must be wider than they are tall (horizontal orientation), sharply focused with good color balance, and submitted as separate JPG files with each file numbered with the figure number. Material must be accompanied by the required copyright transfer statement (see authorship form in Instructions for Authors [http://archderm.ama-assn.org/misc/auinst_crit.pdf]). Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archdermatol.com). Please indicate in your cover letter that the manuscript is a submission to Off-Center Fold. References 1. Winer LH, Sternberg TH, Lehman R, Ashley FL. Tissue reactions to injected silicone liquids: a report of three cases. Arch Dermatol. 1964;90:588-59314206865PubMedGoogle ScholarCrossref 2. Arin MJ, B äte J, Krieg T, Hunzelmann N. Silicone granuloma of the face treated with minocycline. J Am Acad Dermatol. 2005;52(2):(suppl 1) 53-5615692516PubMedGoogle ScholarCrossref 3. Sagi L, Baum S, Lyakhovitsky A, et al. Silicone breast implant rupture presenting as bilateral leg nodules. Clin Exp Dermatol. 2009;34(5):e99-e10119438562PubMedGoogle ScholarCrossref 4. Dragu A, Theegarten D, Bach AD, et al. Intrapulmonary and cutaneous siliconomas after silent silicone breast implant failure. Breast J. 2009;15(5):496-49919624416PubMedGoogle ScholarCrossref 5. Mason J, Apisarnthanarax P. Migratory silicone granuloma. Arch Dermatol. 1981;117(6):366-3677018405PubMedGoogle ScholarCrossref 6. Jansen T, Kossmann E, Plewig G. Siliconoma: an interdisciplinary problem. Hautarzt. 1993;44(10):636-6438225972PubMedGoogle Scholar
Journal
Archives of Dermatology
– American Medical Association
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