BRIEF REPORT Pediatric Dermatology Vol. 32 No. 2 e58–e59, 2015
Colored Pencil-Core Granuloma on the Forehead Abstract: We often encounter injuries caused by pencils or colored pencils in toddlers and young children, but subsequent segmental tumor formation is rare. Here we report the case of a 4-year-old boy who had been stabbed under his left eyebrow with a red pencil. Colored pencil-core granuloma, a foreign body granuloma arising from an injury with a colored pencil, was diagnosed on the basis of intraoperative and histopathologic findings. Because of the severe tissue damage that the colorant causes, this type of tumor grows rapidly within a few days and may be accompanied by resorption of the skull if it occurs on the head or face.
A 4-year-old boy presented at our outpatient clinic with a subcutaneous lesion on the left side of his forehead. He had been stabbed under his left eyebrow with a red pencil approximately 2 months earlier. The lesion was noticed a few days after the injury and had grown gradually. Upon physical examination, a subcutaneous tumor, 15 mm in diameter, was noted. It was elastic, hard, and displaceable upon palpation. Marked skull depression beneath the lesion was also observed. Based on these findings, we suspected a dermoid cyst and performed a tumorectomy. Intraoperatively the tumor was found to be covered with a thick, obviously artificial pink capsule (Fig. 1). A nodular lesion of the same color was detected in the muscle surrounding the tumor and was also removed. The periosteum of the depressed skull was intact on gross examination. Histopathologic examination revealed hemorrhage and crystalline clefts in the central portions of the nodule consisting of multinucleated macrophages encapsulated by fibrous tissue. Fine granule-like particles were observed in the histiocyte cytoplasm and extracellularly. Accordingly, the lesion was believed to be a foreign body reaction to broken
DOI: 10.1111/pde.12524
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pencil lead (Fig. 2). X-ray microscopic analysis of electron-dense intracytoplasmic granules for the study of elemental composition was not available at our institution. Considering the intraoperative and histopathologic findings, the tumor was diagnosed as a colored pencil– core granuloma. At the latest follow-up (10 months after surgery), no tumor recurrence was noted. DISCUSSION Only 30 cases of pencil-core granulomas have been reported. Granick et al (1) reported the first case in 1992 as a thumb lesion after a pencil injury. The authors concluded that this condition should be differentiated from malignant melanoma, as it presented as a rapidly growing, black, subcutaneous tumor after several decades without symptoms. Of the reported cases, only five, including our case, were foreign body granulomas caused by colored pencil injuries. The latent period of this disorder is days, which is much shorter than for granulomas caused by noncolored pencils. Accordingly, Watanabe et al (2) advocated the need to distinguish these
Figure 1. The tumor was covered with a thick, obviously artificial-colored capsule.
© 2015 Wiley Periodicals, Inc.
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occurred only a few days after injury, supporting this mechanism. Regarding skull depression, it is likely that the proinflammatory cytokines interleukin-6 and interleukin-8 or the pressure exerted by the tumor itself was responsible for stimulating osteoclast activity (3,4). In our case, the severe inflammation that the colored pencil core caused and pressure exerted by the granuloma may have accelerated resorption. REFERENCES
Figure 2. Fine granule-like particles were observed in the histiocyte cytoplasm and extracellularly. The scale bar represents 50 lm (hematoxylin and eosin).
lesions from granulomas caused by pencil injuries and named them “colored pencil-core granulomas.” Pencil cores consist of approximately 66% lowtoxicity graphite, 26% silica, and 8% paraffin. Graphite penetration into the tissue takes approximately 30 years, explaining the long latent period for pencil-core granulomas. Colored pencil cores consist mainly of talc, in addition to titanium dioxide, paraffin, colorant, resin, and additives. Colorants can cause severe tissue damage and are capable of penetrating the tissue in only a few days, owing to the presence of watersoluble additives. In our case, tumor formation
1. Granick MS, Erickson ER, Solomon MP. Pencil-core granuloma. Plast Reconstr Surg 1992;89:136–138. 2. Watanabe S, Akazawa S, Aoki R et al. A rapidly growing pencil-core granuloma caused by a blue colored pencil [in Japanese]. J Pediat Dermatol 2012; 31:185–187. 3. Hayashi J, Kuroki Y, Hirakawa K et al. Role of macrophage in osteolysis [in Japanese]. J Jpn Orthop Assoc 1995;69:S1656. 4. Moriyama H, Huang CC, Kato M et al. Effects of pressure on bone resorption in the middle ear of rats. Ann Otol Rhinol Laryngol 1985;94:60–64. Hirokazu Shido, M.D. Ikkei Tamada, M.D., Ph.D. Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan Address correspondence to Hirokazu Shido, M.D., Tokyo Metropolitan Children’s Medical Center, 2-8-29, Musashidai, fuchu-shi, Tokyo 183-8561, Japan, or e-mail: hikkydream1_ [email protected].
Colored Pencil-Core Granuloma on the Forehead Abstract: We often encounter injuries caused by pencils or colored pencils in toddlers and young children, but subsequent segmental tumor formation is rare. Here we report the case of a 4-year-old boy who had been stabbed under his left eyebrow with a red pencil. Colored pencil-core granuloma, a foreign body granuloma arising from an injury with a colored pencil, was diagnosed on the basis of intraoperative and histopathologic findings. Because of the severe tissue damage that the colorant causes, this type of tumor grows rapidly within a few days and may be accompanied by resorption of the skull if it occurs on the head or face.
A 4-year-old boy presented at our outpatient clinic with a subcutaneous lesion on the left side of his forehead. He had been stabbed under his left eyebrow with a red pencil approximately 2 months earlier. The lesion was noticed a few days after the injury and had grown gradually. Upon physical examination, a subcutaneous tumor, 15 mm in diameter, was noted. It was elastic, hard, and displaceable upon palpation. Marked skull depression beneath the lesion was also observed. Based on these findings, we suspected a dermoid cyst and performed a tumorectomy. Intraoperatively the tumor was found to be covered with a thick, obviously artificial pink capsule (Fig. 1). A nodular lesion of the same color was detected in the muscle surrounding the tumor and was also removed. The periosteum of the depressed skull was intact on gross examination. Histopathologic examination revealed hemorrhage and crystalline clefts in the central portions of the nodule consisting of multinucleated macrophages encapsulated by fibrous tissue. Fine granule-like particles were observed in the histiocyte cytoplasm and extracellularly. Accordingly, the lesion was believed to be a foreign body reaction to broken
DOI: 10.1111/pde.12524
e58
pencil lead (Fig. 2). X-ray microscopic analysis of electron-dense intracytoplasmic granules for the study of elemental composition was not available at our institution. Considering the intraoperative and histopathologic findings, the tumor was diagnosed as a colored pencil– core granuloma. At the latest follow-up (10 months after surgery), no tumor recurrence was noted. DISCUSSION Only 30 cases of pencil-core granulomas have been reported. Granick et al (1) reported the first case in 1992 as a thumb lesion after a pencil injury. The authors concluded that this condition should be differentiated from malignant melanoma, as it presented as a rapidly growing, black, subcutaneous tumor after several decades without symptoms. Of the reported cases, only five, including our case, were foreign body granulomas caused by colored pencil injuries. The latent period of this disorder is days, which is much shorter than for granulomas caused by noncolored pencils. Accordingly, Watanabe et al (2) advocated the need to distinguish these
Figure 1. The tumor was covered with a thick, obviously artificial-colored capsule.
© 2015 Wiley Periodicals, Inc.
Brief Report e59
occurred only a few days after injury, supporting this mechanism. Regarding skull depression, it is likely that the proinflammatory cytokines interleukin-6 and interleukin-8 or the pressure exerted by the tumor itself was responsible for stimulating osteoclast activity (3,4). In our case, the severe inflammation that the colored pencil core caused and pressure exerted by the granuloma may have accelerated resorption. REFERENCES
Figure 2. Fine granule-like particles were observed in the histiocyte cytoplasm and extracellularly. The scale bar represents 50 lm (hematoxylin and eosin).
lesions from granulomas caused by pencil injuries and named them “colored pencil-core granulomas.” Pencil cores consist of approximately 66% lowtoxicity graphite, 26% silica, and 8% paraffin. Graphite penetration into the tissue takes approximately 30 years, explaining the long latent period for pencil-core granulomas. Colored pencil cores consist mainly of talc, in addition to titanium dioxide, paraffin, colorant, resin, and additives. Colorants can cause severe tissue damage and are capable of penetrating the tissue in only a few days, owing to the presence of watersoluble additives. In our case, tumor formation
1. Granick MS, Erickson ER, Solomon MP. Pencil-core granuloma. Plast Reconstr Surg 1992;89:136–138. 2. Watanabe S, Akazawa S, Aoki R et al. A rapidly growing pencil-core granuloma caused by a blue colored pencil [in Japanese]. J Pediat Dermatol 2012; 31:185–187. 3. Hayashi J, Kuroki Y, Hirakawa K et al. Role of macrophage in osteolysis [in Japanese]. J Jpn Orthop Assoc 1995;69:S1656. 4. Moriyama H, Huang CC, Kato M et al. Effects of pressure on bone resorption in the middle ear of rats. Ann Otol Rhinol Laryngol 1985;94:60–64. Hirokazu Shido, M.D. Ikkei Tamada, M.D., Ph.D. Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan Address correspondence to Hirokazu Shido, M.D., Tokyo Metropolitan Children’s Medical Center, 2-8-29, Musashidai, fuchu-shi, Tokyo 183-8561, Japan, or e-mail: hikkydream1_ [email protected].
