You know what happens when you “assume”…

  

This is an actual case that crossed my desk recently. It was a decent size skin excision, maybe 3 or 4 cm, from an older woman’s eyebrow, submitted as a “neoplasm”. I have no doubt it was a lumpy bump that bugged her, and maybe it was hard. So when I get a big excision from an older person’s face, I’m thinking it’s going to be a basal cell carcinoma or maybe a big irritated seborrheic keratosis. I was rather surprised to see extensive granulomatous inflammation within the superficial dermis, with associated granular black pigment deposition — basically, a hypersensitivity reaction to what I suspect was tattoo ink, such as in permanent cosmetics. This reaction can occur years after a tattoo; who knows if the ink had all but faded or the patient neglected to mention the tattoo. Certainly most general practitioners are not familiar enough with adverse reactions to cosmetic procedures, including tattoos, to even think of it when presented with a skin lump. Did they clinically think it was a tumor that needed to get cut out? I don’t usually get the backstory on most of my patients, so I don’t know if they’d recognized it as a tattoo reaction and tried to inject it with steroids first, which can sometimes shrink the inflammatory reaction and obviate the need for excision. It might have saved her a surgical procedure and resulting scar.

Moral of the story: don’t assume your health care provider knows everything. They don’t. And they can’t read your mind. As a patient, it’s your responsibility to know your history (was that mole biopsied before? did you put any lotion on the rash already?) and to communicate it, and to ask questions!

With love,
Your pathologist

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