Clinical and Experimental Dermatology
A pigmented lesion on the earlobe C. I. Wootton,1 T. May,2 M. Khan3 and S. L. Walker4 1 Dermatology and 3Histopathology Departments, Queens Medical Centre, Nottingham, UK; 2University of Nottingham, Nottingham, UK; and 4Dermatology Department, Circle NHS Treatment Centre, Nottingham, UK
doi: 10.1111/ced.12515
Clinical findings A 46-year-old woman presented with a unilateral, blue-grey pigmented lesion on her left earlobe, which had been present for at least 3 years (Fig. 1). The lesion had recently become darker, and had also started to bleed when the patient wore earrings. The patient was otherwise well, took no regular medications, and had experienced no previous skin problems. On physical examination, an isolated lesion was seen in the centre of the earlobe at the site of the patient’s ear piercing. The lesion had a blue–grey discolouration, and was visible on both the anterior and posterior aspect of the earlobe. No other lesions were identified, and there was no lymphadenopathy. A punch biopsy was arranged. Figure 1 Black-pigmented lesion on the earlobe.
Histopathological findings On histological examination, a central depression was visible in the epidermis, which was filled with keratin. The epidermis appeared normal. Within the dermis, elastic fibres were coated with darkly pigmented granules (Fig. 2). Perl stain for iron and Masson–Fontana stain for melanin were negative. What is your diagnosis?
Correspondence: Dr Catriona Wootton, Department of Dermatology, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 1 June 2014
ª 2014 British Association of Dermatologists
(b)
(a)
Figure 2 (a) Skin punch biopsy showing brown–black pigment in the dermis; (b) granular brown–black pigment adjacent to dermal elastic fibres. Haematoxylin and eosin, original magnification (a) 9 100; (b) 9 400.
Clinical and Experimental Dermatology (2015) 40, pp457–459
457
D CP
CED
CPD • Clinicopathological case
D
CP
Clinicopathological case
Diagnosis Localized argyria.
Discussion Argyria is the term for silver deposition in the skin, resulting in blue to slate-grey cutaneous discolouration, which may be localized or generalized. Localized argyria is well recognized, with jewellery (particularly earrings) and acupuncture needles being among the most common causes. Historically, generalized argyria was an occupational dermatosis following exposure to silver in refineries, mining and metal manufacturing, but improvements in working conditions such as fume extraction and appropriate ventilation have meant that argyria is now rare.1 Most cases of generalized argyria now seen are secondary to the ingestion or application of silvercontaining medications or alternative remedies, including irrigation solutions for nasal, oral and urethral use, anti-smoking remedies, silver-coated pills, and silver amalgam in dental work. Localized argyria from topical treatments and dressings containing silver nitrate has been described. Occupational argyria may still be seen in workers in contact with silver electroplating solutions or photographic processing, as well as those handling silver, such as jewellers and antique restorers,2 but this tends to result in localized argyria. Patients develop a blue–grey discolouration of the skin, which is most pronounced in sun-exposed sites, and can also affect the nails, sclerae and mucosal surfaces. In the skin, silver is reduced to silver sulfide and silver selenide in a process catalysed by sunlight, which, combined with melanocyte stimulation, leads to the clinical discolouration.3,4 Although it is typically a predominantly cosmetic problem, generalized argyria can lead to systemic problems as a result of silver deposition in other tissues. Fatty degeneration of the liver, heart and kidneys has been reported, as have seizures and neuropathy.3 The differential diagnosis for localized argyria includes endogenous causes such as vascular neoplasms/proliferations, malignant melanoma, blue naevus, Mongolian spot, naevus of Ota or Ito, erythema dyschromicum perstans or ochronosis, and exogenous causes such as such as dental amalgam, tattoo pigment or foreign bodies.5 For more generalized argyria, the differential diagnosis includes drugs (e.g. minocycline, amiodarone, antimalarials, clofazimine), heavy metal toxicity (e.g. gold, bismuth), cyanosis and methaemoglobinaemia.5
458
Clinical and Experimental Dermatology (2015) 40, pp457–459
Blood and urine silver levels may be investigated in generalized argyria. A normal human adult contains about 1 mg of silver,6 and levels over 4 g have been reported to produce generalized argyria.1 Under light microscopy, fine pigmented granules are typically seen in the basement membrane, periadnexally, and surrounding dermal elastic fibres. Silver particles may be visible within the cytoplasm of epithelial and mast cells, or lying free within the dermis. Dark-field illumination highlights the silver granules. Electron microscopy demonstrates bright granules in the dermis, usually within the basal lamina of the eccrine secretory coils and other adnexal structures. Spectral analysis of the granules using a scanning electron microsope usually reveals peaks for silver as well as sulfur and selenium, confirming the diagnosis of argyria.1 In argyria, the pigment deposition is permanent, and treatment options are limited. A few recent case reports support the use of Q-switched Nd:YAG laser for this condition.7 Chelation with agents such as sodium thiosulfate has been tried, as have depigmentary agents such as hydroquinone; in general however, results are disappointing.3
Learning points
•
Argyria refers to silver deposition in the skin, which can be either localized or generalized. • Cutaneous silver deposition results in a bluegrey discolouration of the skin, which is most pronounced at sun-exposed sites. • Silver exposure can occur via occupational exposure, topical and systemic medications or treatments, or direct contact with silver items such as jewellery. • Treatment options are limited and often disappointing.
References 1 Bleehen SS, Gould DJ, Harrington CI et al. Occupational argyria; light and electron microscopic studies and Xray microanalysis. Br J Dermatol 1981; 104: 19– 26. 2 Kapur N, Landon G, Yu RC. Localized argyria in an antique restorer. Br J Dermatol 2001; 144: 191–2. 3 White JML, Powell AM, Brady K et al. Severe generalized argyria secondary to ingestion of colloidal silver protein. Clin Exp Dermatol 2003; 28: 254–6.
ª 2014 British Association of Dermatologists
D CP Clinicopathological case
4 Sato S, Sueki H, Nisijima A. Two unusual cases of argyria: the application of an improved tissue processing method for X-ray microanalysis of selenium and sulphur in silver-laden granules. Br J Dermatol 1999; 140: 158– 63. 5 Rapini RP. Clincal and pathologic differential diagnosis. In: Dermatology, 2nd edn (Bolognia JL, Jorizzo JL, Rapini RP, eds). Amsterdam: Mosby Elsevier, 2008; 9.
ª 2014 British Association of Dermatologists
6 Venugopal B, Luckey TD. Metal toxicity in mammals. In: Chemical Toxicology of Metals and Metalloids (Venugopal B, Luckey TD, eds). New York: Academic Press, 1978; 32–6. 7 Park S-W, Kim J-H, Shin H-T et al. An effective modality for argyria treatment: Q-switched 1,064-nm Nd: YAG laser. Ann Dermatol 2013; 25: 511–12.
Clinical and Experimental Dermatology (2015) 40, pp457–459
459
A pigmented lesion on the earlobe C. I. Wootton,1 T. May,2 M. Khan3 and S. L. Walker4 1 Dermatology and 3Histopathology Departments, Queens Medical Centre, Nottingham, UK; 2University of Nottingham, Nottingham, UK; and 4Dermatology Department, Circle NHS Treatment Centre, Nottingham, UK
doi: 10.1111/ced.12515
Clinical findings A 46-year-old woman presented with a unilateral, blue-grey pigmented lesion on her left earlobe, which had been present for at least 3 years (Fig. 1). The lesion had recently become darker, and had also started to bleed when the patient wore earrings. The patient was otherwise well, took no regular medications, and had experienced no previous skin problems. On physical examination, an isolated lesion was seen in the centre of the earlobe at the site of the patient’s ear piercing. The lesion had a blue–grey discolouration, and was visible on both the anterior and posterior aspect of the earlobe. No other lesions were identified, and there was no lymphadenopathy. A punch biopsy was arranged. Figure 1 Black-pigmented lesion on the earlobe.
Histopathological findings On histological examination, a central depression was visible in the epidermis, which was filled with keratin. The epidermis appeared normal. Within the dermis, elastic fibres were coated with darkly pigmented granules (Fig. 2). Perl stain for iron and Masson–Fontana stain for melanin were negative. What is your diagnosis?
Correspondence: Dr Catriona Wootton, Department of Dermatology, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 1 June 2014
ª 2014 British Association of Dermatologists
(b)
(a)
Figure 2 (a) Skin punch biopsy showing brown–black pigment in the dermis; (b) granular brown–black pigment adjacent to dermal elastic fibres. Haematoxylin and eosin, original magnification (a) 9 100; (b) 9 400.
Clinical and Experimental Dermatology (2015) 40, pp457–459
457
D CP
CED
CPD • Clinicopathological case
D
CP
Clinicopathological case
Diagnosis Localized argyria.
Discussion Argyria is the term for silver deposition in the skin, resulting in blue to slate-grey cutaneous discolouration, which may be localized or generalized. Localized argyria is well recognized, with jewellery (particularly earrings) and acupuncture needles being among the most common causes. Historically, generalized argyria was an occupational dermatosis following exposure to silver in refineries, mining and metal manufacturing, but improvements in working conditions such as fume extraction and appropriate ventilation have meant that argyria is now rare.1 Most cases of generalized argyria now seen are secondary to the ingestion or application of silvercontaining medications or alternative remedies, including irrigation solutions for nasal, oral and urethral use, anti-smoking remedies, silver-coated pills, and silver amalgam in dental work. Localized argyria from topical treatments and dressings containing silver nitrate has been described. Occupational argyria may still be seen in workers in contact with silver electroplating solutions or photographic processing, as well as those handling silver, such as jewellers and antique restorers,2 but this tends to result in localized argyria. Patients develop a blue–grey discolouration of the skin, which is most pronounced in sun-exposed sites, and can also affect the nails, sclerae and mucosal surfaces. In the skin, silver is reduced to silver sulfide and silver selenide in a process catalysed by sunlight, which, combined with melanocyte stimulation, leads to the clinical discolouration.3,4 Although it is typically a predominantly cosmetic problem, generalized argyria can lead to systemic problems as a result of silver deposition in other tissues. Fatty degeneration of the liver, heart and kidneys has been reported, as have seizures and neuropathy.3 The differential diagnosis for localized argyria includes endogenous causes such as vascular neoplasms/proliferations, malignant melanoma, blue naevus, Mongolian spot, naevus of Ota or Ito, erythema dyschromicum perstans or ochronosis, and exogenous causes such as such as dental amalgam, tattoo pigment or foreign bodies.5 For more generalized argyria, the differential diagnosis includes drugs (e.g. minocycline, amiodarone, antimalarials, clofazimine), heavy metal toxicity (e.g. gold, bismuth), cyanosis and methaemoglobinaemia.5
458
Clinical and Experimental Dermatology (2015) 40, pp457–459
Blood and urine silver levels may be investigated in generalized argyria. A normal human adult contains about 1 mg of silver,6 and levels over 4 g have been reported to produce generalized argyria.1 Under light microscopy, fine pigmented granules are typically seen in the basement membrane, periadnexally, and surrounding dermal elastic fibres. Silver particles may be visible within the cytoplasm of epithelial and mast cells, or lying free within the dermis. Dark-field illumination highlights the silver granules. Electron microscopy demonstrates bright granules in the dermis, usually within the basal lamina of the eccrine secretory coils and other adnexal structures. Spectral analysis of the granules using a scanning electron microsope usually reveals peaks for silver as well as sulfur and selenium, confirming the diagnosis of argyria.1 In argyria, the pigment deposition is permanent, and treatment options are limited. A few recent case reports support the use of Q-switched Nd:YAG laser for this condition.7 Chelation with agents such as sodium thiosulfate has been tried, as have depigmentary agents such as hydroquinone; in general however, results are disappointing.3
Learning points
•
Argyria refers to silver deposition in the skin, which can be either localized or generalized. • Cutaneous silver deposition results in a bluegrey discolouration of the skin, which is most pronounced at sun-exposed sites. • Silver exposure can occur via occupational exposure, topical and systemic medications or treatments, or direct contact with silver items such as jewellery. • Treatment options are limited and often disappointing.
References 1 Bleehen SS, Gould DJ, Harrington CI et al. Occupational argyria; light and electron microscopic studies and Xray microanalysis. Br J Dermatol 1981; 104: 19– 26. 2 Kapur N, Landon G, Yu RC. Localized argyria in an antique restorer. Br J Dermatol 2001; 144: 191–2. 3 White JML, Powell AM, Brady K et al. Severe generalized argyria secondary to ingestion of colloidal silver protein. Clin Exp Dermatol 2003; 28: 254–6.
ª 2014 British Association of Dermatologists
D CP Clinicopathological case
4 Sato S, Sueki H, Nisijima A. Two unusual cases of argyria: the application of an improved tissue processing method for X-ray microanalysis of selenium and sulphur in silver-laden granules. Br J Dermatol 1999; 140: 158– 63. 5 Rapini RP. Clincal and pathologic differential diagnosis. In: Dermatology, 2nd edn (Bolognia JL, Jorizzo JL, Rapini RP, eds). Amsterdam: Mosby Elsevier, 2008; 9.
ª 2014 British Association of Dermatologists
6 Venugopal B, Luckey TD. Metal toxicity in mammals. In: Chemical Toxicology of Metals and Metalloids (Venugopal B, Luckey TD, eds). New York: Academic Press, 1978; 32–6. 7 Park S-W, Kim J-H, Shin H-T et al. An effective modality for argyria treatment: Q-switched 1,064-nm Nd: YAG laser. Ann Dermatol 2013; 25: 511–12.
Clinical and Experimental Dermatology (2015) 40, pp457–459
459
