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Tender Cutaneous Neoplasms: Case Reports of
Patients With a Symptomatic Dermatofibroma
and a New Acrostic for Painful Tumors of the
Philip R. Cohen
1. Dermatology, University of California, Davis Medical Center, Sacramento, USA
Corresponding author: Philip R. Cohen, email@example.com
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
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.
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
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
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.
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
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.
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.
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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
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
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.
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].
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Painful tumors of the skin Year Ref
GLENDAbGlomus tumor, leiomyoma, eccrine spiradenoma, neuroma and neurilemmoma, dermatofibroma, and
ENGLANDbEccrine spiradenoma, neuroma, glomus tumor, leiomyoma, angiolipoma, neurilemmoma, and dermatofibroma 1986c
Leiomyoma, eccrine spiradenoma, neuroma, dermatofibroma, angiolipoma, neurilemmoma, endometrioma,
glomus tumor, and granular cell tumor 1993 
Blue rubber bleb nevus, leiomyoma, eccrine spiradenoma, neuroma, dermatofibroma, tufted angioma,
angiolipoma, neurilemmoma, endometrioma, granular cell tumor, and glomus tumor 2019 
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
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
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
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
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 .
cBased on topic-related literature, these acronyms had not been published prior to 1986 .
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 .
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Author Year Contribution Ref
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.
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.
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  and their awareness of the nocturnal pain associated with the
cutaneous venous malformations of blue rubber bleb syndrome. They introduced the acronym BLEND TAN
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 : CALM HOG FLED PEN AND GETS BACK.
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.
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
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
TABLE 2: Landmark contributions in the development of mnemonics for painful tumors of the
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 .
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 . 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 . 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 .
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 . 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 .
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
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 .
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 . 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
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
history None Junctional nevi, plantar verruca None
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
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 . 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 .
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 . 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 . However, these researchers also emphasized that “future
additions to the cutaneous tumor differential diagnosis may require creative additions and rearrangements
to this acronym” .
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 . 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].
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.
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.
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