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Home » Features » Derm DX


DERMDX: PINK PAPULE ON NOSE

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SLIDESHOW

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FIGURE 3. CLOSER VIEW OF HISTOLOGY.




FIGURE 1. PHOTOGRAPH OF PINK PAPULE ON NOSE.




FIGURE 2. SLIDES SHOW A STORIFORM PATTERN OF FIBROHISTIOCYTIC CELLS WITH
INTERMIXEDCELLULAR INFILTRATE, STREAKS OF ENTRAPPED COLLAGEN, AND EPIDERMAL
HYPERPLASIA.



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FIGURE 3. CLOSER VIEW OF HISTOLOGY.




FIGURE 1. PHOTOGRAPH OF PINK PAPULE ON NOSE.




FIGURE 2. SLIDES SHOW A STORIFORM PATTERN OF FIBROHISTIOCYTIC CELLS WITH
INTERMIXEDCELLULAR INFILTRATE, STREAKS OF ENTRAPPED COLLAGEN, AND EPIDERMAL
HYPERPLASIA.



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FIGURE 3. CLOSER VIEW OF HISTOLOGY.



 * CASE STUDY:

 * EXPLANATION:

A 79-year-old man with a history of both basal cell carcinoma and squamous cell
carcinoma presents with a slow-growing lesion on the nose, which he notes has
been growing for 10 years. On examination, an 8-mm pink papule is present on the
left nasal alar rim (Figure 1). A shave biopsy is collected. The histologic
evaluation reveals a storiform pattern of fibrohistiocytic cells with intermixed
cellular infiltrate, streaks of entrapped collagen, and epidermal hyperplasia
(Figures 2 and 3).

Dermatofibroma (DF), also known as a benign fibrous histiocytoma, is a common
slow-growing neoplasm of the skin. These growths typically present as a tan-pink
to reddish-brown papules or nodules on the lower extremity of adults aged 20 to
50 years.1...

Submit your diagnosis to see full explanation.

Dermatofibroma (DF), also known as a benign fibrous histiocytoma, is a common
slow-growing neoplasm of the skin. These growths typically present as a tan-pink
to reddish-brown papules or nodules on the lower extremity of adults aged 20 to
50 years.1 Dermoscopy of the lesion classically displays a central white patch
and peripheral pigment network.2 Lateral compression or pinching of the lesion
often causes central depression, commonly referred to as the dimple sign.3

Histologic evaluation of these lesions characteristically demonstrates a
proliferation of spindle cells and histiocytes, often forming a storiform
pattern.4 The most common histologic features include a dermal proliferation of
spindle cells forming short intersecting fascicles and histiocyte-like cells
admixed with multinucleated giant cells, inflammatory cells, and siderophages.
Above the dermal proliferation, the epidermis is often hyperplastic with
hyperpigmentation of the basal keratinocytes, most commonly over the tips of the
elongated rete ridges. At the periphery of the lesion, there is entrapment of
collagen. Benign dermatofibromas will stain strongly positive for factor XIIIa
and negative for the marker CD34.

Differentiation of dermatofibrosarcoma protuberans from dermatofibroma is
accomplished through immunohistochemistry. Dermatofibrosarcoma protuberans
samples will stain positive for CD 34 and negative for factor XIIIa, which is
opposite to how dermatofibromas will stain.5 Dermatofibrosarcoma protuberans
have a more aggressive clinical course and must be treated appropriately.

Dermatofibroma rarely occurs on the face. There are 2 case series found in the
literature on the infrequent occurrence of these lesions on the face. One of the
series, by Mentzel et al, reported a 0.1% incidence of dermatofibroma occurring
on the face in a database of over 33,000 cases.6 The other series demonstrated a
1.1% incidence of DF occurring on the face in a database of 1800 cases of
dermatofibroma.7 Dermatofibroma presents even less often on the nose with only 7
prior cases of dermatofibroma on the nose found in the literature.6-8 Because of
this reason, dermatofibroma of the nose is not often suspected clinically. The
proposed differential diagnosis often includes basal cell carcinoma, melanocytic
nevi, adnexal neoplasms, or fibrous papules.9

Typically, dermatofibromas can be identified clinically and, unless bothersome
or symptomatic, patients can be reassured on their banal nature with no further
therapy indicated. However, Mentzel et al have suggested that dermatofibromas of
the face are more aggressive than those that occur in more typical locations. In
their case series of 34 dermatofibromas of the face, invasion was seen into deep
tissue and muscle in 50% of cases with a recurrence rate of 18.5%.6
Dermatofibromas occurring in more typical locations, such as the lower
extremities, have a recurrence rate of 1% to 2% despite often incomplete
excision.4 Mentzel et al, therefore, suggested surgeons should take wider
margins for the excision of dermatofibromas on the face.6 More recently, a case
series of 20 patients with dermatofibromas on the face reported few instances of
deep invasion and no recurrences after marginal excision.7 The best treatment
approach for dermatofibromas of the face remains inconclusive and debated.6,7

In the case presented, the fibrohistiocytic cells stained positive for factor
XIIIa and negative for S-100 and CD34. After shave biopsy, no further treatment
was pursued. At 7 months after biopsy, the patient reports no recurrence or
growth in the area.

Caroline Gerhardt, BS, is a medical student at the University of South Florida
Morsani College of Medicine in Tampa; David Aung-Din, MD, works in the
Department of Dermatology, University of South Florida Morsani College of
Medicine; Leslie Turner, MD and Katherina Basic, MD, work in the Department of
Dermatology, James A. Haley Veterans’ Hospitals in Tampa.

REFERENCES

1. Higgins JC, Maher MH, Douglas MS. Diagnosing common benign skin tumors. Am
Fam Physician. 2015;92(7):601-607.

2. Kelati A, Aqil N, Baybay H, Gallouj S, Mernissi FZ. Beyond classic
dermoscopic patterns of dermatofibromas: a prospective research study. J Med
Case Rep. 2017;11(1):266. doi:10.1186/s13256-017-1429-6

3. Fitzpatrick TB, Gilchrest BA. Dimple sign to differentiate benign from
malignant pigmented cutaneous lesions. N Engl J Med. 1977;296(26):1518.
doi:10.1056/NEJM197706302962610

4. Luzar B, Calonje E. Cutaneous fibrohistiocytic tumours – an update.
Histopathology. 2010;56(1):148-165. doi:10.1111/j.1365-2559.2009.03447.x

5. West KL, Cardona DM, Su Z, Puri PK. Immunohistochemical markers in
fibrohistiocytic lesions: factor XIIIa, CD34, S-100 and p75. Am J Dermatopathol.
2014;36(5):414-419. doi:10.1097/DAD.0b013e3182a70396

6. Mentzel T, Kutzner H, Rütten A, Hügel H. Benign fibrous histiocytoma
(dermatofibroma) of the face: clinicopathologic and immunohistochemical study of
34 cases associated with an aggressive clinical course. Am J Dermatopathol.
2001;23(5):419-426. doi:10.1097/00000372-200110000-00006

7. Estela JR, Rico MT, Pérez A, et al. Dermatofibroma of the face: a
clinicopathologic study of 20 cases. Actas Dermosifiliogr. 2014;105(2):172-177.
doi:10.1016/j.ad.2013.10.002

8. Singh S, Patra S, Bhari N. Dermatofibroma over the face. Indian Dermatol
Online J. 2019;10(1):94-95.

9. Sand M, Sand D, Thrandorf C, Paech V, Altmeyer P, Bechara FG. Cutaneous
lesions of the nose. Head Face Med. 2010;6:7. doi:10.1186/1746-160X-6-7

QUESTION

What is the most likely diagnosis?
 * Dermatofibroma
 * Basal cell carcinoma
 * Adnexal neoplasm
 * Melanocytic nevi

1/1
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TOPICS:

Case Studies Dermatology DermDx


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