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Fibrous Papule of the Nose: a Clinicopathological Studyf James H Tnz JOURNAL OF INVESTiGATIVE DERMATOLOGY Vol. 45, No. 3 Copyright 1965 by The Williams & Wilkins Co. Printed in U.S.A. FIBROUS PAPULE OF THE NOSE: A CLINICOPATHOLOGICAL STUDYF JAMES H. GRAHAM, M.D.,t JOHN B. SANDERS, M.D.,t WAINE C. JOHNSON, M.D.t AND ELSON B. HELWIG, M.D.t The usual history of a patient with a fibrousmethods: periodic acid-Schiff (PAS) reaction, with papule of the nose is that of a middle-agedand without diastase digestion; colloidal iron re- person who consults a physician because ofaction (1), with and without bovine testicular hyaluronidase and ribonuelease digestion; Feulgen recent color changes in the lesion or to requestreaction; Fontana-Masson stain for argentaffin removal for cosmetic reasons. These dome-granules (melanin); Snook's reticulum stain; shaped papules are often interpreted clinicallyMovat's pentaehrome I stain (2); Bodian's method as cellular nevi; but their configuration, firmfor nerve fibers and nerve endings; Gomori's iron reaction; Gomori's aldehyde-fuehsin technic; and consistency, and vaseularity may cause confu-the aleian blue method. The pH of the working sion with fibrous proliferations and vascularsolutions, and the methods used in the aldehyde- lesions. fuchsin and alcian blue teehnics and detailed The purpose of this paper is to report ourinterpretation of the results were similar to those described by Johnson and Helwig (3), and John- elinieopathologieal observations of a distinctson, Graham and Helwig (4). Formalia-fixed tissue isolated fibrous papule of the nose, stressingfrom 3 fibrous papules and 2 cellular nevi was used histogenesis, pathogenesis, histoehemical char-for preparing frozen sections for the following fat acteristics, and possible relationship to cellularstains: oil red 0; osmium tetroxide; sudan black B; and the nile blue sulfate stain for neutral fats nevi of the nasal region. and fatty acids. With the exceptions given, the procedures were carried out as outlined in the MATERIALS AND METHODS "Manual of Histologic and Special Staining Tech- nies" (5). The study was conducted on 42 fibrous papules of the nose removed from 40 patients. Tbe ma- CLINICAL DATA terial from 6 of the 40 patients was from The Armed Forces Institute of Pathology (AFIP). The Fibrous papule.—The fibrous papule oc- files of the AFIP include case material from mili-curred predominantly in the Caucasian race. tary, veterans administration and civilian sources. Clinical and pathological observations were sup-Twenty-two patients were men, and 15 were plemented by clinical records, surgical reports,women. The only Negro patients were 2 men. questionnaires, and/or personal interview and ex-The median age of the 40 patients at first amination of the patient. Follow-up data was ob-biopsy or treatment was 41 years. The young- tained from 34 patients. For comparative purposes, est was 14, and the oldest 65 years. The dura- 70 cellular nevi removed from the nose of 65 pa- tients were studied. For purposes of this paper,tion of 2S lesions in 26 patients from stated the term cellular nevus is used to indicate a nevusonset to time of biopsy removal or treatment cell nevus. All specimens were fixed in 10% neutral varied from 3 months to 16 years. The median buffered formalin and the tissue was processed forduration was 3 years, i.e. half of the patients routine paraffin-blocked sections. Multiple sections stained with hematoxylin and eosin were examined had a biopsy diagnosis established within 3 in all eases. Sections from 15 fibrous papules andyears after recognized onset. 10 cellular nevi were prepared by the following The fibrous papule usually appeared dome- shaped and was flesh-colored, pigmented or This investigation was supported in part by re- search training grant no. 2A-5289 (C2), from theangiomatous (Fig. 1). A few of the lesions National Institute of Arthritis and Metabolicwere sessile, polypoid or papillomatous. The Diseases, U. S. Public Health Service, Bethesda, Maryland 20014. majority of the lesions were firm and indurated, Presented by title at the Twenty-fith Annualbut a few were soft. The size of the lesions Meeting of The Society for Investigative Derma-varied from 1 to 5 mm in diameter; the median tology, Inc., San Francisco, Calif., June 21—23, 1964. Received for publication September 25, 1964. was 3 mm. Most patients stated the lesion * From the Skin and Cancer Hospital of Phila-was asymptomatie, although a few mentioned delphia, Department of Dermatology, Templeepisodes of erosion and bleeding usually associ- University School of Medieine,t Philadelphia, Pa. 19140, and The Armed Forces Institute of Pa-ated with trauma. Forty-two lesions from 40 thology4 Washington, D. C. 20305. patients involved the nose as illustrated in 194 FIBROUS PAPULE OF THE NOSE 195 Figure 2. The majority of the lesions were lo- .. cated on the ala nasi. Thirty-eight patients had a single lesion and the other 2 patients had 2 lesions each. The initial clinical diagnosis in 18 patients was cellular nevus. Other diagnoses were: fibrous papule, 7; fibroma, 2; telangiectasia, 2; hemangioma, 2; and keratosis, epithelioma, neurofibroma, verruca, granuloma pyogenicum, ulceration, epidermoid cyst, papilloma, and milia, 1 each. Family history was not significant. Six pa- tients had cellular nevi of the head and neck region confirmed by biopsy examination. One patient had a primary malignant melanoma of the scalp. This latter patient and 1 other had basal cell carcinoma of the skin. Treatment of the fibrous papule was by sur- gical excision in 34 patients, excision and desiccation of the base of the lesion in 5, and FIG. 2. Anatomic distribution of42 fibrous pap- desiccation and curettement in 1. Surgical exci-ules on the nose. sion was by sharp blade removal of the lesion flush with the surface of the surrounding skin. the first biopsy diagnosis of the fibrous The follow-up period for 34 patients, frompapule to the last known status, ranged from 2 months to 9.3 years. The median was 17 months. None of the patients have had recur- rences. Only 1 patient is known to be dead and death was caused by malignant melanoma with widespread metastasis. Six of the 40 pa- tients in the study were lost to follow-up. Cellular nevi.—Cellular nevi of the nose oc- curred predominantly in the Caucasian race. Only 5 of the 65 patients were Negro. Forty- two patients were women, and 23 were men. The median age of the 65 patients at the time of first biopsy or treatment was 37 years. The youngest patient was 13, and the oldest 84 years. The duration of 44 lesions in 41 patients from stated onset to biopsy examination varied from 3 weeks to 78 years; the median was 5 years. Clinically, the majority of the 70 cellular nevi of the nose appeared dome-shaped, smooth, and flesh-colored to brown. A few of the nevi were sessile, polypoid or papillomatous. The consistency of the lesions varied from firm to soft. The size of the lesions varied from 1 to 9 mm in diameter; the median was 4 mm. Fio. 1. Fibrous papules of the nose. One lesion HI5TOPATHOLOGIC AND HISTOCHEMICAL is located near the rounded eminence of the ala nasi and the other at the superior aspect of the OBSERVATIONS nasolabial fold. Both lesions are dome-shaped, but one is flesh-colored, and the other pigmented and Fibrous papule: In hematoxylin- and eosin- angiomatous. stained preparations, the fibrous papules showed a 196 THEJOURNAL OF INVESTIGATIVE DERMATOLOGY dome-shaped or papular to polypoid configura-centric or laminated pattern (Figs. 6 and 7a). In tion, fibrosis and vascular ectasia (Fig. 3). ilyper-a few lesions, the perifollieular fibrosis was asso- keratosis and acanthosis was seen in some exam-ciated with atrophy of the lanugo hairs (Figs. 6 ples, and a few lesions showed superficial erosionand Ia). In the upper eorium, the fibrous prolifera- of the epidermis. Variable numbers of vacuolatedtion showed a tendency to run in wavy fibrillar cells were seen in the epidermis in 34 of the 42strands at right angles to the overlying epidermis lesions (Fig. 4). An increased amount of melanin(Figs. 3 and 4a). A few of the lesions showed pigment was present in the basal layer of the epi-myxomatous features as a part of the fibrous pro- dermis in many specimens. Melanoeytes were lo-liferation. Sebaeeous glands were present in 29. of cated at the dermoepidermal junction, and inthe lesions, and these often appeared rudimentary several specimens these cells were increased inand compressed by the surrounding fibrosis. All number (Fig. 4). The melanocytes in some areasof the lesions showed dilated vessels (Figs. 3, 4a, were grouped in small clusters and others showedand 6), and in some examples there were focal nuclei arranged in a peripheral ring about a cen-areas of eapillary-endothelial proliferation and tral mass of cytoplasm. Sections from 5 of theextravasated red blood cells. lesions showed single theques of nevus cells at the Results of bistoehemical studies were as fol- dermoepidermal junction (Fig. 4), and 1 showedlows: The Fontana-Masson stain for melanin changes resembling senile lentigo. A few lesionsshowed an abundance of pigment in the basal layer showed areas of an indistinct basement membraneof the epidermis and in the lanugo hair follicles at the dermoepidermal junction associated with(Fig. 6). In the eorium, the melanin granules were incontinence of melanin pigment. Focal areas offree, within giant cells and/or melanophages (Fig. inflammation were present in the corium and com-5). The colloidal iron reaction demonstrated re- posed of variable numbers of lymphocytes, histio-active material in the large cutaneous nerves, cyto- cytes, and plasma cells (Fig. 4a). Thirty-six of theplasm of the giant cells, interfibrillar ground sub- lesions contained multinucleated giant cells.
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