ArticlePDF Available

Tender Cutaneous Neoplasms: Case Reports of Patients With a Symptomatic Dermatofibroma and a New Acrostic for Painful Tumors of the Skin

Authors:

Abstract

The most common tender cutaneous neoplasm is a dermatofibroma. The characteristics of three women (35 to 42 years old) with painful dermatofibromas are described. One woman was receiving immunosuppressive therapy for the past decade following a liver transplant; the other women were healthy. The dermatofibroma was located on the buttock, shoulder, and arm, respectively; tumor-related pain had been present for several months to at least a year. The dermal nodules ranged in diameter from 5 millimeters to 12 millimeters and were either flesh-colored to slightly red or brown or tan; one tumor was surrounded by a hyperpigmented patch. Microscopic examination showed the following dermatofibroma variants: classic (fibrocollagenous) in two women and histiocytic in one woman. All the women experienced resolution, without recurrence, of pain following the punch biopsy that only removed the majority (but not all) of the dermatofibroma. Tender cutaneous neoplasms include not only dermatofibromas and other fibrous lesions, but also adipose, bone, calcium, cartilage, eccrine, infiltrative, lymphoproliferative, muscle, neural, and vascular tumors. Acronyms and acrostics are mnemonic devices that have been used by clinicians to aid in recalling the diagnoses associated with painful skin tumors. When there were only 11 or less number of pain-related cutaneous conditions, shorter acronyms associated with either a woman's name, a country or an egg were used. A unique acrostic inspired by Charlotte's Web, a children's book by E. B. White, was created when the differential diagnosis of tender cutaneous neoplasms expanded to 25 tumors. The sequential discovery of additional tender skin lesions resulted in two subsequent minor revisions to the original, hog-related, mnemonic. Herein, a new acrostic -- that is not only able to incorporate the inspiration from Charlotte's Web, but also includes cutaneous lymphoma and a final category of "everything else" in order to maintain the future integrity of mnemonic -- for the painful tumors of the skin is proposed: HOG FLED PEN AND GETS CALM LIFE BACK (hidradenoma, osteoma cutis, glomus tumor, fibromyxoma [superficial acral], leiomyosarcoma [cutaneous], eccrine angiomatous hamartoma, Dercum's disease, piezogenic pedal papule, eccrine spiradenoma, neurilemmoma, angiolipoma, neuroma, dermatofibroma, granular cell tumor, endometriosis [cutaneous], thrombus [cutaneous organizing], scar, calcinosis cutis, angioendotheliomatosis [reactive], leiomyoma, metastases [cutaneous], lymphoma [cutaneous], intravenous lobular capillary hemangioma, foreign body [and foreign body reaction], everything else, blue rubber bled nevus, angioma [tufted], chondrodermatitis nodularis helicis, and keloid).
Review began 09/18/2022
Review ended 09/22/2022
Published 09/28/2022
© Copyright 2022
Cohen. This is an open access article
distributed under the terms of the Creative
Commons Attribution License CC-BY 4.0.,
which permits unrestricted use, distribution,
and reproduction in any medium, provided
the original author and source are credited.
Tender Cutaneous Neoplasms: Case Reports of
Patients With a Symptomatic Dermatofibroma
and a New Acrostic for Painful Tumors of the
Skin
Philip R. Cohen
1. Dermatology, University of California, Davis Medical Center, Sacramento, USA
Corresponding author: Philip R. Cohen, mitehead@gmail.com
Abstract
The most common tender cutaneous neoplasm is a dermatofibroma. The characteristics of three women (35
to 42 years old) with painful dermatofibromas are described. One woman was receiving immunosuppressive
therapy for the past decade following a liver transplant; the other women were healthy. The dermatofibroma
was located on the buttock, shoulder, and arm, respectively; tumor-related pain had been present for several
months to at least a year. The dermal nodules ranged in diameter from 5 millimeters to 12 millimeters and
were either flesh-colored to slightly red or brown or tan; one tumor was surrounded by a hyperpigmented
patch. Microscopic examination showed the following dermatofibroma variants: classic (fibrocollagenous) in
two women and histiocytic in one woman. All the women experienced resolution, without recurrence, of
pain following the punch biopsy that only removed the majority (but not all) of the dermatofibroma. Tender
cutaneous neoplasms include not only dermatofibromas and other fibrous lesions, but also adipose, bone,
calcium, cartilage, eccrine, infiltrative, lymphoproliferative, muscle, neural, and vascular tumors. Acronyms
and acrostics are mnemonic devices that have been used by clinicians to aid in recalling the diagnoses
associated with painful skin tumors. When there were only 11 or less number of pain-related cutaneous
conditions, shorter acronyms associated with either a woman’s name, a country or an egg were used. A
unique acrostic inspired by Charlotte’s Web, a children’s book by E. B. White, was created when the
differential diagnosis of tender cutaneous neoplasms expanded to 25 tumors. The sequential discovery of
additional tender skin lesions resulted in two subsequent minor revisions to the original, hog-related,
mnemonic. Herein, a new acrostic -- that is not only able to incorporate the inspiration from Charlotte’s
Web, but also includes cutaneous lymphoma and a final category of “everything else” in order to maintain
the future integrity of mnemonic -- for the painful tumors of the skin is proposed: HOG FLED PEN AND
GETS CALM LIFE BACK (hidradenoma, osteoma cutis, glomus tumor, fibromyxoma [superficial acral],
leiomyosarcoma [cutaneous], eccrine angiomatous hamartoma, Dercum’s disease, piezogenic pedal papule,
eccrine spiradenoma, neurilemmoma, angiolipoma, neuroma, dermatofibroma, granular cell tumor,
endometriosis [cutaneous], thrombus [cutaneous organizing], scar, calcinosis cutis, angioendotheliomatosis
[reactive], leiomyoma, metastases [cutaneous], lymphoma [cutaneous], intravenous lobular capillary
hemangioma, foreign body [and foreign body reaction], everything else, blue rubber bled nevus, angioma
[tufted], chondrodermatitis nodularis helicis, and keloid).
Categories: Dermatology, Family/General Practice, Internal Medicine
Keywords: tumor, tender, skin, painful, neoplasm, mnemonic, dermatofibroma, dermal, cutaneous, acronym
Introduction
Painful tumors of the skin include a variety of benign and malignant neoplasms. They include adipose, bone,
calcium, cartilage, eccrine, fibrous, infiltrative, lymphoproliferative, muscle, neural, and vascular tumors.
Mnemonic devices -- such as acronyms and acrostics -- have been created to aid clinicians in remembering
the differential diagnosis of painful skin tumors [1-8].
Dermatofibroma is a common benign cutaneous neoplasm. A solitary tumor may be the consequence of an
insect bite at the site of the lesion whereas some of the individuals with multiple lesions may have an
acquired condition that alters their immunity or be a recipient of treatment with an immunosuppressive
agent or both. Most dermatofibromas present as asymptomatic dermal papules or nodules; however, albeit
less frequently, the tumor may be painful [9-15].
The clinical features of three women, each of whom developed a painful dermatofibroma, are described. In
addition, the characteristics of tender dermatofibromas that have been reported in other individuals are
summarized. Also, previous and current mnemonics for tender cutaneous lesions are reviewed and a new
acrostic for painful tumors of the skin is proposed.
Case Presentation
1
Open Access Case
Report DOI: 10.7759/cureus.29713
How to cite this article
Cohen P R (September 28, 2022) Tender Cutaneous Neoplasms: Case Reports of Patients With a Symptomatic Dermatofibroma and a New
Acrostic for Painful Tumors of the Skin. Cureus 14(9): e29713. DOI 10.7759/cureus.29713
Case one
A 42-year-old Philippine woman presented with a tender lesion on her left buttock of approximately one-
year duration. It had begun as a small dark spot and had continued to slowly enlarge. She had no previous
skin cancers or dermatologic conditions.
A complete cutaneous examination was done. A protuberant, painful, brown 12 x 12-millimeter dermal
nodule surrounded by a hyperpigmented 3 x 2-centimeter patch was observed on the lateral and inferior
area of her left buttock (Figures 1A-1C). A three-millimeter biopsy from the nodular portion of the skin
lesion, using the punch technique, was performed.
FIGURE 1: Morphologic features of a painful dermatofibroma on the
buttock
Distant (A) and closer (B, C) views of a painful dermatofibroma (within the black oval) on the lateral and inferior
area of her left buttock of a 42-year-old Philippine woman. The tender tumor had been present for approximately
12 months and appears as a hyperpigmented 3 x 2-centimeter patch surrounding a protuberant brown 1.2 x 1.2-
centimeter dermal nodule.
Microscopic evaluation of the tissue specimen showed a benign spindle cell tumor, consisting of a
predominance of collagen and fibroblasts in a whorled arrangement, extending from the deeper portion of
the papillary dermis into the reticular dermis and extending to the lateral margin of the specimen;
compressed collagen bundles, having a keloidal appearance, were noted at the periphery of the neoplasm. A
grenz zone of the normal-appearing papillary dermis was noted between the underlying dermal tumor and
the overlying epidermis. The epidermis showed acanthosis and orthokeratosis (Figures 2A-2D).
2022 Cohen et al. Cureus 14(9): e29713. DOI 10.7759/cureus.29713 2 of 11
FIGURE 2: Pathologic features of a tender dermatofibroma in a 42-year-
old Philippine woman
Distant (A) and closer (B-D) views of microscopic findings of painful dermatofibroma (of the classic or
fibrocollagenous variant). The epidermis (A, B) shows not only increased thickening of the stratum corneum
without retention of nuclei within the cells (orthokeratosis, demonstrated by the yellow vertical bars), but also
thickening of the other layers (acanthosis, demonstrated by the red vertical bars). Beneath the epidermis, in the
dermis above the tumor, there is an area of normal-appearing papillary derm is (solid green circles) referred to as a
Grenz zone (A, B). The dermal tumor (within the black ovals) appears as a whorled arrangement of fibroblasts
and collagen (A, B, D); it extends from the papillary dermis into the reticular dermis. At the periphery of the
dermatofibroma (A, C), the collagen bundles are compressed and have a keloid-like appearance (black arrows)
(Hematoxylin and eosin: A, x4; B, x10; C, x20; D, x20).
The correlation of the clinical presentation and the pathology findings established the diagnosis of a painful
dermatofibroma of the classic variant; this tumor has also been referred to as a fibrocollagenous
dermatofibroma. Most of the benign dermal neoplasm had been removed during the biopsy; therefore, the
residual tumor and surrounding hyperpigmentation were observed. The dermatofibroma-associated pain
completely resolved after the biopsy site had healed and there has been no recurrence of pain at the site.
Case two
A 37-year-old Hispanic woman presented with a painful lesion on her left shoulder of several
months duration. It had begun as a small tan patch that had grown to its current size and become painful.
She also had warts on her feet.
Her medical history was significant for a liver transplant 10 years earlier and episodic migraine headaches.
Her transplant-related medications included 1,000 milligrams daily of mycophenolate mofetil and two
milligrams twice daily of tacrolimus. She would take 50 milligrams of sumatriptan when she began to
develop a headache. Her plantar warts were being treated topically by applying 40% salicylic acid pads daily.
A complete cutaneous examination was done. A slightly raised, painful, tan 5 x 5-millimeter dermal nodule
was noted on the left shoulder proximal to her arm (Figures 3A, 3B); dimpling of the skin was observed when
the corresponding area was pinched between the clinician’s thumb and index finger. A 3-millimeter punch
biopsy, from the center of the tender skin lesion, was performed.
2022 Cohen et al. Cureus 14(9): e29713. DOI 10.7759/cureus.29713 3 of 11
FIGURE 3: Clinical presentation of a tender dermatofibroma on the
shoulder
Distant (A) and closer (B) views of a painful dermatofibroma of several months duration on the left shoulder
(proximal to the arm) of a 37-year-old Hispanic woman who was a liver transplant recipient ten years earlier and
has been maintained on daily, transplant-related immunosuppressive therapy consisting of mycophenolate mofetil
and tacrolimus. The tender dermatofibroma of the classic or fibrocollagenous variant (A, B) appears as a tan 5 x
5-millimeter, slightly raised, dermal nodule (within the black circle). In addition, benign-appearing pigmented
lesions, clinically consistent with junctional nevi (black arrows) are present on the left chest (A) and left shoulder
(A, B). Also, on the left chest above the breast (within the red oval), a healed scar can be noted (A).
Two benign-appearing brown patches were noted on the left shoulder (superior and medial to the painful
dermal lesion) and left chest; clinically the lesions were consistent with junctional nevi. In addition, there
was a healed scar on her left chest above the breast. Also, several verrucous papules were present on the
great toe and plantar surface of her left foot; these were plantar verruca.
Microscopic evaluation of the tissue specimen from the left shoulder showed a non-circumscribed, benign-
appearing, fibrocellular tumor in the reticular dermis. The tumor consisted of intertwining bands of collagen
interspersed with predominantly fibroblasts and occasional histiocytes. The epidermis was acanthotic and
its basal layer was hyperpigmented.
The correlation of the clinical presentation and the pathology findings established the diagnosis of a painful
dermatofibroma of the classic variant. Almost all the dermal tumors had been removed during the biopsy
and the site of the residual dermatofibroma was clinically observed. The pain previously associated with the
dermatofibroma did not persist after the biopsy and did not recur.
Case three
A 35-year-old Caucasian woman presented with a painful mass on her left upper extremity of at least 12
months duration. It had begun as a small bump and became tender as it grew. The patient was healthy and
had no other skin conditions.
A complete cutaneous examination was done. A prominent, tender, flesh-colored to slightly red 8 x 8-
millimeter dermal nodule was observed on the left extensor mid-arm (Figures 4A, 4B). A three-millimeter
biopsy from the center of the nodule, using the punch technique, was performed.
2022 Cohen et al. Cureus 14(9): e29713. DOI 10.7759/cureus.29713 4 of 11
FIGURE 4: A tender dermatofibroma presenting as a painful dermal
nodule on the arm
Distant (A) and closer (B) views of the painful histiocytic dermatofibroma of at least one-year duration appearing
as a flesh-colored to slightly red 8 x 8-millimeter prominent dermal nodule (within the black circle) on the left
extensor mid-arm of a 35-year-old Caucasian woman. A pen with black ink (B) was used to draw eight lines
toward the lesion until the dermal component was contacted in order to approximate the diameter of the
dermatofibroma.
Microscopic evaluation of the tissue specimen showed a dermal tumor, consisting of numerous histiocytes
and some fibroblasts that extended to the lateral margin of the specimen; within the benign neoplasm, there
was hemosiderin and phagocytosis of lipid by the histiocytes. There was acanthosis of the overlying
epidermis.
The correlation between the clinical presentation and the pathology findings established the diagnosis of a
painful dermatofibroma of the histiocytic variant. The biopsy site healed; the site and residual tumor were
clinically observed. The dermatofibroma-associated pain resolved without recurrence.
Discussion
Several neoplasms are included in the differential diagnosis of painful dermal tumors (Table 1) [1-6]. The
tender skin lesion typically presents as a cutaneous nodule that is either flesh-colored or maybe blue,
brown, purple, or red. Microscopic evaluation of a tissue specimen -- obtained during biopsy or excision of
the lesion -- is usually necessary to establish the diagnosis [1-6].
2022 Cohen et al. Cureus 14(9): e29713. DOI 10.7759/cureus.29713 5 of 11
Acronym
or
acrostica
Painful tumors of the skin Year Ref
GLENDAbGlomus tumor, leiomyoma, eccrine spiradenoma, neuroma and neurilemmoma, dermatofibroma, and
angiolipoma 1986c[2]
ENGLANDbEccrine spiradenoma, neuroma, glomus tumor, leiomyoma, angiolipoma, neurilemmoma, and dermatofibroma 1986c[2]
LEND AN
EGG
Leiomyoma, eccrine spiradenoma, neuroma, dermatofibroma, angiolipoma, neurilemmoma, endometrioma,
glomus tumor, and granular cell tumor 1993 [2]
BLEND
TAN EGG
Blue rubber bleb nevus, leiomyoma, eccrine spiradenoma, neuroma, dermatofibroma, tufted angioma,
angiolipoma, neurilemmoma, endometrioma, granular cell tumor, and glomus tumor 2019 [3]
CALM HOG
FLED PEN
AND GETS
BACK
Calcinosis cutis, angioendotheliomatosis (reactive), leiomyoma, metastases (cutaneous), hidradenoma (also
referred to as clear cell acrospiroma, clear cell hidradenoma, eccrine acrospiroma, nodular hidradenoma, and
solid-cystic hidradenoma), osteoma cutis, glomus tumor, fibromyxoma (digital, which is also referred to as a
superficial acral fibromyxoma), leiomyosarcoma (cutaneous and originating in either the dermis or
subcutaneous tissue), eccrine angiomatous hamartoma, Dercum’s disease, piezogenic pedal papule, eccrine
spiradenoma, neurilemmoma, angiolipoma, neuroma, dermatofibroma, granular cell tumor, endometriosis
(cutaneous), thrombus (cutaneous organizing thrombus which was originally referred to as a capillary
aneurysm of the skin), scar, blue rubber bled nevus, angioma (tufted variant), chondrodermatitis nodularis
helicis, and keloid
2019 [4]
CALM
HOGS
FLED
PENS AND
GET BACK
Calcinosis cutis, angioendotheliomatosis (reactive), leiomyoma, metastases (cutaneous), hidradenoma,
osteoma cutis, glomus tumor, scar, fibromyxoma (superficial acral), leiomyosarcoma (cutaneous), eccrine
angiomatous hamartoma, Dercum’s disease, piezogenic pedal papule, eccrine spiradenoma, neurilemmoma,
something else (including foreign body such as solder and a reaction to the foreign body), angiolipoma,
neuroma, dermatofibroma, granular cell tumor, endometriosis (cutaneous), thrombus (cutaneous organizing),
blue rubber bled nevus, angioma (tufted), chondrodermatitis nodularis helicis, and keloid
2020 [5]
IF HOGS
FLED PEN,
CALM AND
GET BACK
Intravenous lobular capillary hemangioma, foreign body (reaction), hidradenoma, osteoma cutis, glomus
tumor, scar, fibromyxoma, leiomyosarcoma, eccrine angiomatous hamartoma, Dercum’s disease (adiposis
dolorosa), piezogenic pedal papule, eccrine spiradenoma, neurilemmoma (schwannoma), calcinosis cutis,
angioendotheliomatosis, leiomyoma, metastases, angiolipoma, neuroma, dermatofibroma, granular cell tumor,
endometriosis, thrombus, blue rubber bled nevus, angioma, chondrodermatitis nodularis helicis, and keloid
2022 [6]
HOG FLED
PEN AND
GETS
CALM LIFE
BACK
Hidradenoma, osteoma cutis, glomus tumor, fibromyxoma (superficial acral), leiomyosarcoma (cutaneous),
eccrine angiomatous hamartoma, Dercum’s disease, piezogenic pedal papule, eccrine spiradenoma,
neurilemmoma, angiolipoma, neuroma, dermatofibroma, granular cell tumor, endometriosis (cutaneous),
thrombus (cutaneous organizing), scar, calcinosis cutis, angioendotheliomatosis (reactive), leiomyoma,
metastases (cutaneous), lymphoma (cutaneous), intravenous lobular capillary hemangioma, foreign body (and
foreign body reaction), everything else, blue rubber bled nevus, angioma (tufted), chondrodermatitis nodularis
helicis, and keloid
2022 CR
TABLE 1: Acronyms and acrostics for painful tumors of the skin
Abbreviations: CR, current report; Ref, reference.
aAids that can be used to assist a person in remembering something are referred to as mnemonic devices. Acronyms and acrostics are mnemonic
devices. An acronym is usually one word, but can be several words, made up of the first letters of other words that you want to remember. An acrostic,
similar to an acronym, uses the first letter of each item you want to remember to create a memorable sentence or phrase.
bPrior to these acronyms, a table of painful tumors of the skin was published in 1985 and included leiomyomas, glomus tumor, eccrine spiradenoma,
neuroma, and neurilemmoma [1].
cBased on topic-related literature, these acronyms had not been published prior to 1986 [2].
Dermatofibroma, also referred to as a fibrous histiocytoma, maybe a painful dermal tumor. However, this
benign neoplasm was not included in the manuscript that summarized tender cutaneous lesions by
Thompson in 1985 (Table 2) [1-8]. Subsequently, dermatofibroma was incorporated into the early acronyms
(such as GLENDA and ENGLAND) for painful tumors of the skin (Table 1) [1-6]. Indeed, Naversen et al.
considered dermatofibroma to be the most common of the painful lesions when they included the tumor in
their LEND AN EGG acronym [2].
2022 Cohen et al. Cureus 14(9): e29713. DOI 10.7759/cureus.29713 6 of 11
Author Year Contribution Ref
Thompson 1985
The author reported a 24-year-old man with biopsy-confirmed multiple painful pilar leiomyoma on his left chest
from the mid-sternum to the areola; the pain was relieved with oral nifedipine (10 mg three or four times daily). A
table summarizing painful tumors of the skin (leiomyomas, glomus tumor, eccrine spiradenoma, neuroma, and
neurilemmoma) was included in the paper.
[1]
Naversen,
et al. 1993
The authors described a 19-year-old woman with a biopsy-confirmed granular cell tumor on her right chest that
was painful and tender; this lesion was not included in the prior acronyms, such as GLENDA and ENGLAND, for
painful skin tumors. Therefore, the authors also created a new acronym for painful tumors of the skin (LEND AN
EGG) based upon the woman’s tumor, a reviewed of a dermatopathology textbook for lesions listed as either
painful or tender, and their clinical experience; their mnemonic remained unchanged for 25 years.
[2]
Bhat, et
al.a2019
The authors modified the acronym by Naversen et al. based upon a 31-year-old man with three painful acquired
tufted angiomas on the left side of his chest [7] and their awareness of the nocturnal pain associated with the
cutaneous venous malformations of blue rubber bleb syndrome. They introduced the acronym BLEND TAN
EGG.
[3]
Cohen, et
al. 2019
The authors encountered two women with painful skin tumors that were not listed in the prior acronym: a 53-
year-old with an organizing thrombus that presented as a tender firm nodule on her lateral left foot and a 56-
year-old whose osteoma cutis lesion presented as a tender nodule on her left lower abdomen. After an
extensive review of the literature, combined with their clinical experience, the authors discovered 25 painful skin
tumors and introduced a new acrostic for painful tumors of the skin based upon the children’s book Charlotte’s
Web [8]: CALM HOG FLED PEN AND GETS BACK.
[4]
Cohen, et
al. 2020
The authors evaluated a 74-year-old man with a painful lesion of several years duration on his right leg; 15
years earlier, hot solder had dripped onto the site and become embedded beneath the skin. Since foreign body
(solder) and the cutaneous reaction to the foreign body were not included in their recently introduced acrostic,
the authors modified it by moving an ‘S’ (from GETS to create HOGS) and adding an ‘S’ (changing PEN to
PENS) in order to add the new diagnosis of ‘something else’ (which would include not only foreign body and
foreign body reaction, but also allow for additional painful tumors in the future). Their new mnemonic became
CALM HOGS FLED PENS AND GET BACK.
[5]
Sargent,
et al. 2022
The authors assessed a 70-year-old woman with a tender, slowly enlarging, blue-tinged subcutaneous nodule
on her right proximal dorsal forearm for several months; an excisional biopsy revealed an intravascular lobular
capillary hemangioma. The authors modified Cohen et al.’s mnemonic by removing the ‘S’ (something else) from
PENS and adding the word ‘IF’ to include intravascular lobular capillary hemangioma and foreign body
(reaction): IF HOGS FLED PEN, CALM AND GET BACK. However, the authors also emphasized that “future
additions to the cutaneous tumor differential diagnosis may require creative additions and rearrangements to this
acronym.”
[6]
Cohen 2022
The author presents the features of three women with painful dermatofibromas. The author also adds not only
another painful skin tumor (lymphoma of the skin including B-cell lymphomas, T-cell lymphomas, and Hodgkin
lymphoma), but also an ‘everything else’ category for the inclusion of future painful cutaneous neoplasms.
Hence, the word ‘IF’ from Sargent et al.’s acronym is changed to ‘LIFE’ and the words are more appropriately
arranged to create a new acrostic for painful tumors of the skin: HOG FLED PEN AND GETS CALM LIFE
BACK.
CR
TABLE 2: Landmark contributions in the development of mnemonics for painful tumors of the
skin
Abbreviations: CR, current report; Ref, reference.
aTwelve years earlier (in 2005), one of the coauthors (Dr. Ramesh M. Bhat) along with two additional investigators described a 31-year-old man with
multiple painful acquired tufted angiomas of 1.5 years duration on his chest [7].
Several clinical and pathologic variants of dermatofibroma have been described [9,10]. A dermatofibroma
commonly presents as a hyperpigmented dermal papule or nodule; however, the lesion can be
hypopigmented to pink and it can be atrophic or depressed below the surrounding epithelium. A distinctive
clinical characteristic of a dermatofibroma, the dimple sign, can be elicited when an individual uses their
thumb and index finger to pinch the skin adjacent to the lesion; depression of the tumor and the
surrounding skin, creating a dimple, is observed [2-4].
Microscopic examination of a dermatofibroma shows a dermal tumor consisting of benign fibroblasts and/or
histiocytes. Compression and thickening of the collagen at the periphery of the tumor may be present
2022 Cohen et al. Cureus 14(9): e29713. DOI 10.7759/cureus.29713 7 of 11
creating keloidal-appearing collagen bundles. The overlying epidermis may demonstrate hyperkeratosis
(morphologically appearing scaly), acanthosis (appearing as thickening of the epithelium), and basal layer
hyperpigmentation (accounting for the darker color of the lesion clinically). In addition, some of the tumors
have a Grenz zone of normal-appearing papillary dermis between the epidermis above and the dermal
neoplasm below [9,10].
Dermatofibroma researchers have observed that some of the tumors were symptomatic. In a retrospective
study of 122 biopsy-confirmed specimens of dermatofibromas from 92 patients, nearly 60% of the lesions
were asymptomatic; however, 20.5% (25 tumors) were tender, 11.5% (14 tumors) were painful, and 9.8% (12
tumors) were pruritic [9]. Another study evaluated 75 tumors (including 72 dermatofibromas and three
dermatomyofibromas) from 70 patients, between six months to 18 years old, and noted that the neoplasm
was either painful or hypersensitive to touch in 27% (19 of 70) of the children [10]. Although the
pathogenesis of dermatofibroma-associated pain remains to be established, one group of investigators has
speculated that dermatofibroma-related pain develops as a result of entrapping the collagen bundles by the
adjacent interlacing tumor strands of fibroblasts or histiocytes [3].
Aneurysmal dermatofibroma is a unique variant of this neoplasm with distinctive clinical presentation and
pathologic features. Morphologically, they can be larger, cystic, and appear blue, black, or dark red; in
addition, they can be associated with rapid growth and pain. Histologically, in addition to fibrous solid
areas, up to half of the tumor consists of large, blood-filled, histiocyte-lined tissue spaces containing
hemosiderin pigment, fibroblasts, and foam cells [11,12].
Cruz and Kyriakos are credited for the initial description of aneurysmal dermatofibroma. Their study
included 17 cases from 14 women and three men. The lesion was described as painful in five (29%) of the
patients [11]. Subsequently, Hoyt et al. described the features of a painful, biopsy-confirmed, aneurysmal
dermatofibroma of three to four years duration on the left anteromedial thigh of a 30-year-old man. The
lesion appeared as a moderately firm, violaceous 10 x 15-millimeter nodule beneath and surrounded by a
pink scaly 3 x 2-centimeter patch with peripheral hyperpigmentation. Physical exertion would exacerbate
the pain; however, oral administration of over-the-counter analgesics and topical application of ice packs
would provide relief of the pain [12].
Atrophic dermatofibroma is another variant of dermatofibroma with characteristic morphologic and
histologic features. Clinically, the tumor presents as a solitary patch with a central umbilication; it is most
commonly found on either the shoulder, leg, or back of women over age 48 years. Pathologically, it has
similar changes observed in non-atrophic dermatofibromas; however, in the central atrophic portion of the
tumor, the dermis is often at least 50% thinned and the elastic fibers are either decreased or absent in this
area [13].
Atrophic dermatofibroma has been reported in at least 102 individuals; two of these men had tumors that
were transiently painful and demonstrated not only atrophic changes but also aneurysmal histologic
characteristics. The first patient was a 27-year-old man who presented with an asymptomatic brown
atrophic patch of two years duration on his back that had been temporarily painful and swollen one year
earlier; a biopsy of the tumor was diagnosed as an aneurysmal dermatofibroma with atrophic features and
the residual neoplasm was completely excised. The second patient was a 40-year-old man who had an
asymptomatic nodular lesion of ten years duration on his left upper trunk that had become painful during
the previous 12 hours; examination showed a five-centimeter hemorrhagic plaque that evolved into a
hematoma during the subsequent week and then progressed into an asymptomatic depressed lesion two
months later. The lesion was completely excised and demonstrated an atrophic dermatofibroma in the
atrophic zone accompanied by aneurysmatic changes in the non-atrophic area [13].
Single case reports of painful tumors in individuals with other variants of dermatofibroma have also been
described. A 25-year-old woman with a deep penetrating dermatofibroma of her right foot presented with a
slowly growing painful mass of two months duration that made walking difficult; the tumor was completely
excised and the dermatofibroma-associated pain gradually subsided [14]. Another patient, a 19-year-old
woman, presented with a 2.1 x 1.5 x 1.0-centimeter nodule on her medial left thigh that was tender to touch;
a diagnosis of subcutaneous dermatofibroma was established after evaluation of the completely excised
tumor [15].
Three patients, each with a painful dermatofibroma, are described in this report; their characteristics are
summarized in Table 3. The women ranged in age from 35 to 42 years (median, 37 years); one of the women
was a liver transplant recipient and was receiving immunosuppressive therapy. Lesion-associated pain had
been present for several months to at least a year (median, approximately one year). The benign tumors
presented as flesh-colored to slightly red or brown or tan dermal nodules (with or without surrounding
hyperpigmentation) that ranged in size from 5 x 5 millimeters to 12 x 12 millimeters (median, 8 x 8
millimeters) and were located on either the buttock or shoulder or arm. Two women had a classic
(fibrocollagenous) dermatofibroma and the third woman had a histiocytic dermatofibroma. Pain resolved
after the biopsy and did not recur even though there was microscopic evidence of residual tumor following
the biopsy of the lesions.
2022 Cohen et al. Cureus 14(9): e29713. DOI 10.7759/cureus.29713 8 of 11
Features Patient one Patient two Patient three
Age 42-year-old 37-year-old 35-year-old
Race Philippine Hispanic Caucasian
Gender Woman Woman Woman
Medical history None Liver transplant, migraine
headaches Healthy
Dermatology
history None Junctional nevi, plantar verruca None
Skin cancer
history None None None
Duration Approximately one year Several months At least 12 months
Location Left buttock Left shoulder Left arm
Symptoms Pain Pain Pain, pruritus
Morphology Protuberant, brown dermal nodule
surrounded by a hyperpigmented patch Slighty raised, tan dermal nodule Prominent, tender, flesh-colored to
slightly red dermal nodule
Size 12 x 12-millimeters nodule within 3 x 2-
centimeter patch 5 x 5-millimeters 8 x 8-millimeters
Dermatofibroma
variant Classic (fibrocollagenous) Classic (fibrocollagenous) Histiocytic
Treatment Incomplete removal by punch biopsy
followed by observation
Incomplete removal by punch
biopsy followed by observation
Incomplete removal by punch
biopsy followed by observation
Follow-up Pain resolved without recurrence Pain resolved without recurrence Pain resolved without recurrence
TABLE 3: Characteristics of patients with a painful dermatofibroma
In addition to dermatofibroma, there are many other tumors of the skin that are painful. Mnemonic devices
have been used as memory aids to facilitate remembering the differential diagnosis of painful skin tumors
(Table 1) [1-6]. As additional cutaneous conditions were discovered to be painful, new acronyms and
acrostics were created to accommodate the diagnoses (Table 2) [1-8].
Earlier acronyms for painful skin tumors were limited to seven, nine, or 11 conditions [2,3]. However, the
differential diagnosis eventually expanded to 25 conditions [4]. Indeed, based on the extensive differential
diagnosis of tender cutaneous neoplasms, investigators created a unique acrostic that was inspired by E. B.
White’s children’s book Charlotte’s Web [8].
When these investigators subsequently encountered an individual with a painful skin lesion caused by a
foreign body (solder) and the cutaneous reaction to that foreign body, they modified their original acrostic
by adding a “something else” category [5]. Yet, within two years, other researchers not only removed the new
category, but also added two more conditions -- foreign body (reaction) and intravascular lobular capillary
hemangioma -- and also changed the acrostic [6]. However, these researchers also emphasized that “future
additions to the cutaneous tumor differential diagnosis may require creative additions and rearrangements
to this acronym” [6].
Since the most recently proposed acrostic, a thorough review of the literature has revealed another painful
tumor of the skin: lymphoma. Shelley and Wood observed that pain was a prominent symptom associated
with occult malignant lymphomas in the skin of 50% (three of six) of their patients [16]. Subsequently,
painful cutaneous lymphomas have been reported in patients with primary cutaneous B-cell lymphoma,
subcutaneous panniculitis-like T-cell lymphoma, mycosis fungoides (tumor stage), and primary cutaneous
Hodgkin lymphoma [17-20].
Thus, lymphoma of the skin should be added to the list of differential diagnoses for tender cutaneous
neoplasms. However, in an attempt to maintain the integrity of the acrostic for painful skin tumors, it is also
reasonable to add an additional category (which would be designated “everything else”) for new painful
cutaneous lesions that are subsequently discovered. Hence, after modification and word rearrangement of
2022 Cohen et al. Cureus 14(9): e29713. DOI 10.7759/cureus.29713 9 of 11
the most recent mnemonic device, a new acrostic for painful skin tumors that still maintains its inspiration
from Charlotte’s Web is proposed: HOG FLED PEN AND GETS CALM LIFE BACK (Table 1) [1-6].
Conclusions
There are several benign and malignant tumors that can present as tender cutaneous neoplasms.
Dermatofibroma is a commonly occurring benign tumor that usually appears as an asymptomatic dermal
papule or nodule. However, approximately 30% of dermatofibromas have presented as a painful or tender
lesions. Indeed, dermatofibromas are the most common diagnosis associated with a painful tumor of the
skin. The characteristics of three women with symptomatic dermatofibromas are reported; a punch biopsy,
which removed some but not all, of the painful dermal nodule, not only established the diagnosis of the
neoplasm but also resulted in resolution of the dermatofibroma-associated pain without recurrence. In
addition to dermatofibromas and other fibrous lesions, tender cutaneous neoplasms include tumors of
adipose, bone, calcium, cartilage, eccrine, lymphoproliferative, infiltrative, muscle, neural, and vascular
origin. Mnemonic devices have been created to aid clinicians in remembering the differential diagnosis of
painful skin tumors. Shorter acronyms (such as GLENDA, ENGLAND, LEND AN EGG, and BLEND TAN EGG)
were adequate when the number of possible pain-related cutaneous conditions was 11 or less. When the
differential diagnosis of tender cutaneous neoplasms expanded to 25 tumors, an acrostic inspired by E. B.
White’s children’s book Charlotte’s Web was created; subsequently, two minor revisions to the mnemonic
were published for each additional tender skin lesion that was identified. With the addition of cutaneous
lymphoma and a final category of “everything else” to maintain the integrity of mnemonic, a new acrostic
for the painful tumors of the skin -- that is still able to incorporate the inspiration from Charlotte’s Web --
has been proposed: HOG FLED PEN AND GETS CALM LIFE BACK.
Additional Information
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: Philip R. Cohen, MD declare(s) personal fees from ParaPRO. Dr.
Cohen is a consultant for ParaPRO. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.
References
1. Thomas JA Jr: Therapy for painful cutaneous leiomyomas. J Am Acad Dermatol. 1985, 13:865-7.
10.1016/s0190-9622(85)70230-7
2. Naversen DN, Trask DM, Watson FH, Burket JM: Painful tumors of the skin: “LEND AN EGG” . J Am Acad
Dermatol. 1993, 28:298-300. 10.1016/0190-9622(93)70039-v
3. Bhat MR, George AA, Jayaraman J: Painful tumors of the skin - from ENGLAND to LEND AN EGG to BLEND
TAN EGG. Indian J Dermatol Venereol Leprol. 2019, 85:231-4. 10.4103/ijdvl.IJDVL_1165_16
4. Cohen PR, Erickson CP, Calame A: Painful tumors of the skin: "CALM HOG FLED PEN AND GETS BACK" .
Clin Cosmet Investig Dermatol. 2019, 12:123-32. 10.2147/CCID.S193359
5. Cohen PR, Skupsky H, Erickson C, Calame A: Foreign body (solder) and reaction to the foreign body
presenting as a cutaneous tender tumor: case report and a new acronym to aid in recalling the differential
diagnosis of painful skin lesions. Cureus. 2020, 12:e6955. 10.7759/cureus.6955
6. Sargent B, Birmingham SW, Skupsky H: Intravenous lobular capillary hemangioma: a case report and
proposal for new cutaneous tender tumor differential diagnosis acronym. Cureus. 2022, 14:e28030.
10.7759/cureus.28030
7. Kamath GH, Bhat RM, Kumar S: Tufted angioma. Int J Dermatol. 2005, 44:1045-7. 10.1111/j.1365-
4632.2005.02270.x
8. White EB: : Charlotte’s Web. Harper & Brothers, New York, NY; 1952.
9. Han TY, Chang HS, Lee JH, Lee WM, Son SJ: A clinical and histopathological study of 122 cases of
dermatofibroma (benign fibrous histiocytoma). Ann Dermatol. 2011, 23:185-92. 10.5021/ad.2011.23.2.185
10. Berklite L, Ranganathan S, John I, Picarsic J, Santoro L, Alaggio R: Fibrous histiocytoma/dermatofibroma in
children: the same as adults?. Hum Pathol. 2020, 99:107-15. 10.1016/j.humpath.2020.03.012
11. Santa Cruz DJ, Kyriakos M: Aneurysmal ("angiomatoid") fibrous histiocytoma of the skin . Cancer. 1981,
47:2053-61. 10.1002/1097-0142(19810415)47:8<2053::aid-cncr2820470825>3.0.co;2-a
12. Hoyt BS, Hedayat A, LeBlanc RE, Glass JS: Painful violaceous nodule with peripheral hyperpigmentation .
Cutis. 2018, 101:E6-8.
13. Cohen PR, Erickson CP, Calame A: Atrophic dermatofibroma: a comprehensive literature review . Dermatol
Ther (Heidelb). 2019, 9:449-68. 10.1007/s13555-019-0309-y
14. Chung J, Namkoong S, Sim JH, Lee JS, Hong SP, Kim MH, Park BC: Deep penetrating benign fibrous
histiocytoma of the foot associated with throbbing pain. Ann Dermatol. 2011, 23:S239-42.
10.5021/ad.2011.23.S2.S239
15. Kaur H, Kaur J, Gill KS, Mannan R, Arora S: Subcutaneous dermatofibroma: a rare case report with review of
literature. J Clin Diagn Res. 2014, 8:FD01-2. 10.7860/JCDR/2014/6586.4204
16. Shelley WB, Wood MG: Observations on occult malignant lymphomas in the skin . Cancer. 1976, 38:1757-70.
10.1002/1097-0142(197610)38:4<1757::aid-cncr2820380451>3.0.co;2-g
17. Heinzerling L, Dummer R, Kempf W, Schmid MH, Burg G: Intralesional therapy with anti-CD20 monoclonal
2022 Cohen et al. Cureus 14(9): e29713. DOI 10.7759/cureus.29713 10 of 11
antibody rituximab in primary cutaneous B-cell lymphoma. Arch Dermatol. 2000, 136:374-8.
10.1001/archderm.136.3.374
18. Zhang M, Tang X, Zhou H, Liao Q, Han J, Chen X: Diffuse painful erythema on right thigh . JAAD Case Rep.
2021, 16:120-3. 10.1016/j.jdcr.2021.06.032
19. Jones CL, Green WL, Gilley-Avramis J: Elderly woman with painful forearm rash . Ann Emerg Med. 2020,
76:805-18. 10.1016/j.annemergmed.2020.06.044
20. Hakkou D, Belefqih I, Sabri S, et al.: Primary cutaneous Hodgkin’s lymphoma: an extremely rare entity .
Cureus. 2021, 13:e19272. 10.7759/cureus.19272
2022 Cohen et al. Cureus 14(9): e29713. DOI 10.7759/cureus.29713 11 of 11
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Introduction An atrophic dermatofibroma is a benign fibrohistiocytic neoplasm. It typically presents as an asymptomatic patch with a depressed central area. Methods The PubMed database was used to search the following words: atrophic, dermatofibroma, elastic and fibers. The relevant papers and their references generated by the search were reviewed. Images of the clinical and pathological features of two patients with an atrophic dermatofibroma are presented. In addition, a comprehensive review of the characteristics of this unique dermatofibroma is provided. Results An atrophic dermatofibroma has been reported in 102 patients: 53 women, 11 men and 38 individuals whose gender was not provided. It typically appeared as an asymptomatic solitary patch with a central umbilication—most commonly on the shoulder or lower extremity or back—of women aged 48 years or older. Dermoscopy typically showed white scar-like patches; a patchy pigment network was also noted in some lesions. The pathology of an atrophic dermatofibroma has the same features that can be observed in a common fibrous dermatofibroma; there is acanthosis, basal layer hyperpigmentation, and induction of basal cell carcinoma-like features, hair follicle formation or sebaceous hyperplasia in the epidermis and a proliferation of spindle-shaped fibroblasts in the dermis. However, atrophic dermatofibromas also demonstrate depression of the central surface and thinning of the dermis; in many cases, the dermal atrophy is at least 50%. Elastic fibers are either decreased or absent. Similar to non-atrophic dermatofibromas, the immunoperoxidase profile of atrophic dermatofibromas is factor XIIIa-positive and cluster of differentiation 34 (CD34)-negative. The pathogenesis of atrophic dermatofibromas remains to be established. Conclusion An atrophic dermatofibroma is an uncommon benign variant of a dermatofibroma. The diagnosis can be suspected based on clinical features and dermatoscopic findings. A biopsy of the lesion will confirm the diagnosis. Periodic evaluation of the lesion site is a reasonable approach to the management of the residual tumor.
Article
Full-text available
Painful tumors of the skin present as dermal or subcutaneous nodules. They can originate from several sources: adipose tissue, cartilage degeneration, deposition of bone or calcium, eccrine glands, fibrous tissue, infiltration of benign (endometrium) or malignant (metastatic neoplasm) tissue, muscle, nerve, or vascular structures. Although pathologic evaluation of the lesion is necessary to determine the diagnosis, it is possible to make a reasonable differential diagnosis based on knowledge of prior tumors that have appeared as tender lesions. Two women with painful skin tumors – either osteoma cutis or an organizing thrombus – are described. Based on our clinical experience and review of the literature, 25 painful skin tumors were identified: chondrodermatitis nodularis helicis, angioendotheliomatosis, leiomyoma, metastases, hidradenoma, osteoma cutis, glomus tumor, fibromyxoma, leiomyosarcoma, eccrine angiomatous hamartoma, Dercum’s disease, peizogenic pedal papule, neurilemmoma, angiolipoma, neuroma, dermatofibroma, granular cell tumor, endometriosis, thrombus, scar, blue rubber bleb nevus, angioma, calcinosis cutis, and keloid. An acronym – inspired by Charlotte’s Web, a book that many children have read – that can be used as a memory aid for recalling the list of painful skin tumors is introduced: “CALM HOG FLED PEN AND GETS BACK”.
Article
Here, we report a case of a 70-year-old female who presented with a slowly enlarging tender nodule on the right forearm for several months. Physical examination showed a faintly blue-tinged freely mobile subcutaneous nodule. Excision was complicated by greater than expected bleeding and revealed an unexpected intravenous mass. Histopathology demonstrated capillary lobules separated by fibrous septae within a vein, consistent with intravenous lobular capillary hemangioma (IVLCH). IVLCH is a rare benign capillary proliferation of unclear etiology. Excision is typically curative and relieves any pain and discomfort the patient might be experiencing. With the addition of IVLCH, we respectfully propose a new acronym for the differential diagnosis of cutaneous tender tumors: intravenous lobular capillary hemangioma, foreign body (reaction), hidradenoma, osteoma cutis, glomus tumor, scar, fibromyxoma, leiomyosarcoma, eccrine angiomatous hamartoma, Dercum's disease (adiposis dolorosa), piezogenic pedal papule, eccrine spiradenoma, neurilemmoma (schwannoma), calcinosis cutis, angioendotheliomatosis, leiomyoma, metastases, angiolipoma, neuroma, dermatofibroma, granular cell tumor, endometriosis, thrombus, blue rubber bleb nevus, angioma, chondrodermatitis nodularis helicis, and keloid ("IF HOGS FLED PEN, CALM AND GET BACK"). Future additions to the cutaneous tender tumor differential diagnosis may require creative additions and rearrangements to this acronym. However, continual updates will allow it to serve both clinicians and pathologists alike as a comprehensive representation of etiologies to consider for cutaneous tender tumors.
Article
Skin involvement in Hodgkin's lymphoma (HL) is rare. The diagnosis can be difficult, mainly due to the wide range of cutaneous lesions that can be observed, but also due to the differential diagnosis, even after the immunohistochemical staining. We present the case of a 30-year-old man who presented with a painful cutaneous nodular lesion; biopsy and immunohistochemical stains were consistent with classic HL. The patient was treated with adriamycin, bleomycin, vinblastin, and dacarbazine (ABVD) with complete remission.
Article
Fibrous histiocytoma (FH) or dermatofibroma are common cutaneous lesions mostly seen in adults and rare in the first two years of life. Two hundred sixty seven patients less than 18 years with a diagnosis of FH or dermatomyofibroma, a lesion with morphologic overlap with FH, were identified from the files of a single institution with only 13 (4.8 %) occurring in patients under 5 years of age. Ten patients had either underlying neurologic, autoimmune, or metabolic disorders or a family history of autoimmune conditions. Histologic review of H&E and immunostains from 75 FH and dermatomyofibroma in 70 patients showed: 33 classic FH, 8 classic FH characterized by a peculiar retiform morphology with thin fascicles of elongated cells forming a network reminiscent of the eruptive variant of FH, 19 deep/cellular, 5 aneurysmal, 3 lipidized (including two lesions in a patient affected by Mucopolysacharidosis IV), 3 dermatomyofibromas, and 4 isolated cases of hemosiderotic, granular cell atypical, and epithelioid FH. Immunostains for Factor XIIIa highlighted a dense network of dendritic cells in FH which was significantly reduced in the FH with retiform morphology. Smooth muscle actin staining was positive in a high percentage of FH (85.3%). The current series demonstrates that FH in children may show unique clinical and morphologic features. The retiform pattern with decreased dendritic cells found in congenital lesions and in two older patients with lesions in two locations, might have a different pathogenesis, probably related to an altered immune response in very young patients.
Article
Cutaneous tender tumors manifest as painful dermal or subcutaneous masses. Acronyms, a memory aid created from the initial letters of other words, can be used to assist in recalling a list of conditions. We report the case of a man who presented with a painful lesion on his leg; 15 years earlier, hot solder had embedded beneath his skin at that location. The subcutaneous mass was removed, and his symptoms resolved. Microscopic evaluation of the specimen showed a foreign body reaction to metal. Therefore, after correlating his medical history, clinical presentation, and pathology findings, the diagnosis of a foreign body (solder) and a foreign body reaction to solder, as a cause of the patient's painful skin lesion, was established. Including our patient's diagnosis for his painful skin lesion, the list of conditions that have been described as presenting as a cutaneous tender tumor include calcinosis cutis, angioendotheliomatosis, leiomyoma, metastases, hidradenoma, osteoma cutis, glomus tumor, scar, fibromyxoma, leiomyosarcoma, eccrine angiomatous hamartoma, Dercum's disease, piezogenic pedal papule, eccrine spiradenoma, neurilemmoma, something else (such as foreign body (solder) and a reaction to the foreign body), angiolipoma, neuroma, dermatofibroma, granular cell tumor, endometriosis, thrombus, blue rubber bleb nevus, angioma, chondrodermatitis nodularis helicis, and keloid. We introduce a novel acronym for painful lesions of the skin that was inspired by the book Charlotte's Web in which a barn spider (Charlotte), by weaving praises of a pig (Wilbur) into her web, is responsible for the pig's life being spared. Wilbur is a calm pig; however, there was an episode when he temporarily fled his pen and was subsequently induced, with a pail of slop, to get back into the pen. The new acronym for cutaneous tender tumors uses the initial letter of each of the 26 currently established painful skin lesions: CALM HOGS FLED PENS AND GET BACK.