Pencil-Core Granuloma

A 75-year-old woman presented with a bluish discoloration, measuring 1 cm in diameter, on the dorsal surface of the terminal phalanx of her right index finger. The patient reported that she had stuck the tip of her finger with a lead pencil 50 years earlier. At the time, the point of the pencil had broken off and remained lodged in her finger. In the intervening years, the mass had slowly enlarged, changed color, and become tender (Panel A, arrow). Histologic examination of a biopsy specimen (Panel B) showed degenerative tissue with calcification (arrows) and granulomas associated with histiocytes laden with fragments of black graphite. On the basis of the clinical presentation and pathologic findings, we determined this lesion to be a pencil-core granuloma. The core of a pencil is composed of graphite, clay, wax, and lacquer. Each of these components may cause delayed granulomatous reactions in the skin. Thus, as in this case, pencil-tip injury should be considered when black granular fragments are found in cutaneous tissue. The pencil granuloma was not removed, in accordance with the patient's wishes. After 10 months of clinical observation, there were no changes in its size or color.

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