DP16 A rare metallic facial eruption: aluminium granulomas following ear piercings

Abstract A 17-year-old girl presented with a 3-year history of progressive bilateral changes to her earlobes. She had had her ears pierced, which initially resulted in the areas becoming inflamed. It was unclear whether this was due to an allergic reaction or infection. Over time, thickened tissue developed at the lower earlobes and seemed to extend to the jawline, accompanied with occasional itching and throbbing. She had a history of mild childhood eczema. She noted similar reactions, such as redness and itching, to necklaces and facial exfoliators. On examination, there was bilateral, erythematous, well-circumscribed induration below the earlobes, extending to the jawline. The affected areas measured 7.5 × 3.5 cm on the right and 7 × 2 cm on the left. There was no palpable lymphadenopathy or active eczema. Patch testing was considered to exclude a contact allergy. However, this was negative to facial cosmetic fragrances and metals. In view of the induration, magnetic resonance imaging revealed symmetrical high T2 short-tau inversion recovery signals in the preauricular subcutaneous fat, extending along the margins of the masseter muscles without involving deeper structures. Prominent reactive lymph nodes were noted. A diagnostic biopsy of the affected area showed epidermal changes with focal necrosis and crusting indicating external trauma. In the superficial and deep dermis, there was perivascular lymphohistiocytic inflammatory cell infiltration. In subcutaneous tissue, there was an infiltrate of lymphocytes, mature plasma cells and histiocytes that contained granular, violaceous material. The pathologist felt that the histology represented foreign material, based on the morphological findings, although the location was very unusual. They felt it represented an aluminium granulomatous reaction pattern. Aluminium is commonly used as an adjuvant in vaccines and can cause delayed tissue reactions at injection sites (Bergfors E, Trollfors B, Inerot A, Gente Lidholm A. Contact allergy to aluminium induced by commonly used pediatric vaccines. Clin Transl Med 2017; 6: 4). While aluminium-related reactions from earrings have not been previously reported, it was hypothesized that her initial earrings may have contained aluminium. She did not respond to a reducing course of prednisolone and was subsequently started on methotrexate at a dose of 15 mg weekly. After 3 months of treatment, she reported softening of the indurated areas. This case highlights a rare presentation of aluminium granulomatous reaction, following an ear piercing.