Auricular Pyogenic Granuloma Triggered by a Nonpiercing Ear Cuff

Summary:

Pyogenic granuloma (PG) is an acquired benign vascular lesion commonly affecting the skin and mucous membranes across all age groups. It is often triggered by minor trauma or chronic irritation, with the head and neck region being the most frequently involved (36%). Although PG can resolve spontaneously, surgical intervention is often warranted due to cosmetic concerns, bleeding, or pain. Auricular PG is rare, accounting for approximately 1% of cases, and has been linked to ear piercings. We present the first reported case of auricular PG associated with the use of a nonpiercing ear cuff. Given that ear cuffs are generally considered safe accessories, this case underscores the importance of recognizing such devices as potential triggers. It also highlights the utility of scanning electron microscopy and energy-dispersive x-ray spectroscopy in identifying embedded metals that may contribute to chronic inflammation.

Pyogenic granuloma (PG) is a common benign vascular lesion of the skin and mucous membranes, often triggered by minor trauma or chronic irritation. It most frequently occurs in the head and neck region, accounting for approximately 36% of cases.^1,2 Although PG can regress spontaneously, surgical removal is often required due to cosmetic concerns, bleeding, or pain.

In the auricle, PG is typically associated with piercings. Reports of auricular PG without piercing history are extremely rare. However, chronic inflammation from embedded metals—such as nickel or titanium—can induce granulomatous reactions even without visible trauma.

This case report highlighted that nonpiercing metal accessories such as ear cuffs, which are generally considered safe, can also trigger complications, including contact dermatitis, metal allergy, and PG. We emphasized that persistent inflammation may result from embedded metal allergens in the dermis.³

We presented a rare case of auricular PG caused by a nonpiercing ear cuff and discussed the possible role of embedded metallic particles in its pathogenesis. This report underscored the importance of recognizing nonpiercing accessories as potential triggers of granulomatous skin reactions.

CASE REPORT

A 30-year-old woman developed localized erythema and pruritus on her auricle within hours of wearing an ear cuff for the first time, prompting immediate removal. The cuff was approximately 1.5 cm in diameter and 0.5 cm in width. (See figure, Supplemental Digital Content 1, which displays a schematic illustration showing the position and design of the nonpiercing ear cuff worn by the patient at the onset of symptoms. The illustration is based on the patient’s recollection and depicts a ring-shaped accessory placed on the helix of the auricle, https://links.lww.com/PRSGO/E615.) By the next day, she experienced intense itching and stinging pain at the same site and was diagnosed with contact dermatitis. Topical corticosteroids were prescribed, but the symptoms persisted. Patch testing confirmed nickel sensitivity, supporting metal-induced dermatitis. Although there was no visible skin trauma, these findings suggest that metal particles penetrated a transiently impaired skin barrier and remained embedded, acting as persistent immune triggers.

Years later, the area gradually elevated into a growing nodule, prompting surgical consultation (Fig. 1). She had never worn pierced earrings and had no history of trauma, surgery, or infection involving the auricle.

Fig. 1.

Clinical, pathological, and analytic findings. A clinical photograph of the auricle at presentation.

The lesion was surgically excised. Mild residual redness remained, possibly reflecting trace metals in the surrounding dermis. The patient is being managed conservatively with topical corticosteroids. Further surgical intervention may be considered if inflammation persists.

Histopathology revealed lobular capillary proliferation, inflammatory infiltration, and increased collagen in the dermis, consistent with PG. No epidermal abnormalities or malignancy were observed (Fig. 2).

Fig. 2.

Histopathologic examination revealed lobular proliferation of capillaries with inflammatory infiltration and dense collagen deposition (H&E stain).

The composition of the discarded ear cuff could not be analyzed because it had been thrown away before the patient’s visit. To explore the presence of residual metallic elements potentially responsible for prolonged inflammation, the excised specimen was analyzed using scanning electron microscopy (SEM) and energy-dispersive x-ray spectroscopy (EDS). Trace amounts of titanium, iron, chromium, and nickel were detected in 21 distinct locations within the tissue (Fig. 3). No recurrence was observed during 1 year of follow-up (Fig. 4).

Fig. 3.

Elemental analysis using EDS detected trace amounts of Fe, Cr, Ni, Mo, and Ti in the lesion.

Fig. 4.

Clinical photograph at the 1-year follow-up, showing complete healing without recurrence or deformity.

DISCUSSION

This is the first documented case of PG associated with a nonpiercing ear cuff. Although it is theoretically possible for nonpiercing metal accessories to induce local inflammation, we found no prior reports of auricular PG caused by ear cuffs. Therefore, this case remains unique and provides novel insight into granulomatous reactions in the absence of piercing. PG typically presents as a rapidly growing, red nodule prone to bleeding. Excision is usually needed for cosmetic or functional reasons. Identifying etiological factors is essential for prevention, especially in atypical cases.

In our case, although the lesion developed gradually and lacked the typical appearance of PG, histopathologic analysis revealed characteristic lobular capillary proliferation in the dermis, confirming the diagnosis. PG most commonly affects the head and neck region (36%), with auricular involvement being relatively rare. It is typically associated with trauma or piercings. Therefore, PG arising in the auricle of a patient without any piercing history is extremely uncommon.

SEM and EDS revealed titanium, chromium, nickel, and iron. Although titanium is generally considered biocompatible, several reports have shown that it can cause hypersensitivity reactions and granuloma formation in susceptible individuals.^3–5 Nickel and chromium are known allergens linked to chronic inflammation. Prior reports have documented granuloma formation with embedded trace metals from piercings.^3,6,7

In our patient, patch testing confirmed nickel sensitivity, and it is likely that the metal particles entered the dermis through a transiently compromised skin barrier caused by acute contact dermatitis. These embedded metals may have acted as persistent immune triggers, leading to granulomatous inflammation and eventual nodule formation. Even in the absence of overt trauma or piercing, trace metals can penetrate damaged skin and remain within the dermis, eliciting delayed hypersensitivity reactions.⁸

Although ear cuffs are considered noninvasive and generally safe, this case demonstrated that even nonpiercing metal accessories can lead to significant dermatologic complications when used on compromised skin. SEM and EDS analyses were useful in detecting trace metals within the lesion, and histopathologic examination provided a definitive diagnosis. The integration of elemental analysis and histopathology was crucial in identifying the underlying pathogenesis in this atypical case.

This case underscores the need to consider metal hypersensitivity in persistent auricular nodules, even without piercing. A detailed history of accessory and elemental analysis should be considered in unexplained granulomatous skin lesions. Although this is a single-case report and lacks experimental verification, it provides important insight into the potential risks of nonpiercing metal accessories. Written informed consent was obtained from the patient, and ethical approval was not required for this single-case report, in accordance with institutional policy.

DISCLOSURES

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

ACKNOWLEDGMENTS

The authors sincerely thank all individuals who contributed to this study. Special thanks to Dr. Shoichiro Takakuma for his assistance in specimen preparation and to Hitachi High-Tech, Japan, for their support in the metal analysis.

ETHICAL APPROVAL

This case report was conducted in accordance with institutional guidelines. Ethical approval was deemed unnecessary for a single-patient case report.