Abstract

A 62-year-old man presented to the dermatologist with concern of a non-painful, intermittently “draining”, scaled, pink papule on the right elbow for at least two years. A superficial tangential biopsy performed revealed histologic features of epidermal hyperkeratosis and spired papillomatosis, consistent with verruca vulgaris. Within one week of biopsy, the patient reported recurrence at the site with further exophytic, soft, pink tissue extruding from the biopsy wound. The decision to re-scallop the depth of the lesion was made, with histology now revealing a polypoid lesion with denuded epidermis and atrophic dermis composed of ectatic vessels and intermixed adipocyte lobules. The histologic features of protruding adipose and adnexal/vascular structures dermally with no recurrent verruca or carcinoma identified were suggestive of tissue herniation. Notably, upon further history-taking, the patient reported prior ipsilateral carpal and cubital tunnel release surgeries five years prior. He noted an asymptomatic flesh-colored papule present on that elbow for several years following the tunnel releases but no further trauma to that site. The histologic features of hyperkeratosis on initial superficial biopsy with dermal herniation of adipose and adnexal structures on deeper re-biopsy within the clinical context of prior surgical trauma at the site are reminiscent of piezogenic papules, which have been described on heels and wrists with repeated mechanical pressure. We propose a novel entity - piezogenic granuloma of the elbow - blending the occurrence of this lesion with preceding trauma similar to pyogenic granulomas and the dermal herniation of adipose/adnexa akin to piezogenic papules.