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Sports-induced targetoid erythema due to paintball projectile.

A 25-year-old healthy white male was incidentally noted to have asymptomatic annular lesions on his trunk and extremities on a routine full body examination.

Diagnosis: Sports-induced targetoid erythema due to paintball projectile

The skin often displays unique patterns that allow for the identification of the mechanism of injury. Specifically, the type, pattern, and distribution of injury may suggest a certain diagnosis. A broad differential can include projectile trauma, burns (electrical, chemical, and physical), primary dermatologic conditions (not discussed further), and non-accidental self-inflicted trauma or physical abuse. Unique cultural practices should also be considered, including cupping, coining, spooning, moxibustion, and salting. Chronic trauma can also result in unique patterns of injury associated with certain activities, including rower's rump (lichenified plaques), surfer's nodules, cyclist's nodules, yoga sign (sitting position calluses), and jogger's nipples (erosions).

The type of injury may provide clues to the mechanism of injury. Epidermal damage secondary to a tangential or crushing force leaves an abrasion, whereas deeper dermal damage results in a contusion. Both abrasions and contusions may display an imprint pattern of the inflicting object or a material juxtaposed between the skin and the object (such as a clothing zipper). Rigid objects (such as a hammer, pliers, screwdriver, or a belt buckle) are more likely than flexible objects (such as a whip or shoe) to leave a readily apparent imprint. Tearing of tissue results in a laceration with tissue bridging and variable patterns of deformation. Traction alopecia may present with irregular hair loss. Thermal injury typically induces blisters followed by necrosis, whereas electrocution results in a centrally charred lesion with raised borders and surrounding erythema. Chemical burns may present as a linear or rounded defect with a more severely damaged central zone where the exposure was greatest. Phytophotodermatitis from furocoumarin exposure (limes or celery) presents with irregular, linear erythema and blisters.

Specific objects leave differing patterns of injury. Physical abuse is more likely if an imprint is readily discernible (such as a fork, curling iron, or hot plate). Clues to factitial dermatitis include linearity and unnaturally appearing defects with angulated borders. Impact from linear objects (e.g. baseball bat) generate parallel contusions with a central pallor as extravasated blood from ruptured capillaries is displaced laterally. Similarly, forceful slaps produce a negative imprint, human kicks generate a shoe imprint, and motor vehicle tire treads induce polygonal abrasions or patterned contusions. Parallel elongated curvilinear contusion lines (loop marks) encircling a limb may result from a rope, belt, or cord used as a whip. Human bites produce isolated semicircular contusions or abrasions. Chain necklaces generate complex abrasions with a distinct identifiable chain pattern. Motor vehicle accidents may result in tempered glass dicing injuries (groups of short, angulated incisions with linearity) or radio knob-, steering wheel-, and airbag-shaped contusions. Forceful grabbing may leave multiple 1-1.5 cm circular fingertip abrasions. Strangulation by a ligature presents with a skin indentation, abrasion, and petechial facial hemorrhages. A double-edged knife blade leaves a V-shape at both margins whereas a single-edged weapon shows one blunt end. Accompanying hesitation marks (superficial, parallel incisions) suggests a self-inflicted origin. A Phillips screwdriver may produce four abrasions around a central puncture wound.

A gunshot entry wound produces range-dependent patterns. From a distance, gunshots produce a round or elliptical perforation with an abrasion collar (the gyrating bullet abrades the inverted skin). Close-range gunshots may induce powder tattoo marks or punctate abrasions from powder grains. Gunshots with barrel-to-skin contact produce seared skin edges or stellate tears from subcutaneous gas-induced tearing. Gunshot exit wounds typically lack surrounding features.

The injury distribution can also illuminate the mechanism of injury or the associated circumstance (e.g. % abuse). Multiple clustered ecchy-moses of uniform shape over the " upper arms, medial thighs, trunk, ears, neck, genitalia, or areas without an underlying bony prominence may indicate physical abuse. Accidental contact burns are typically patchy, solitary, and superficial due to the withdrawal reflex. While nonaccidental cigarette burns are characterized by multiple, circumscribed, full-thickness imprints, accidental cigarette contact results in single, tangentially oriented lesions.

Intentional liquid burns are often symmetric, clearly demarcated, and located on the lower extremities and perineum in a stocking distribution with flexural crease sparing (zebra stripes) or donut hole sparing (the buttocks is spared due to contact with the colder bathtub). Accidental liquid burns are superficial, involve the upper extremities or trunk, show splash marks, and lack definite demarcation. Grease burns are often associated with cooking oil fires, occur on the upper extremity or face, and require excision or grafting due to the severity of damage. A gasoline explosion is usually superficial with periorbital sparing of rhytides, whereas gasoline flames involve clothed areas and demonstrate sharply demarcated full-thickness involvement. Electrical flashes cause superficial defects, spare rhytides, and present with accompanying soot deposits.

The current case resulted from projectile-induced trauma. Sport-induced targetoid erythema results from skin impact by high-velocity objects encountered during sporting games (typically, paintball, table tennis, racquetball, and squash). The impact results in targetoid erythema (central area of normal skin with a surrounding erythematous annular ring) that may become purpuric (paintball trauma may present immediately with purpuric lesions). The angle of impact determines the relationship between the erythematous flare pattern and the central clearing.

This case and photo were submitted by Mark Ash, MS, East Carolina University, Greenville, N.C., and Donna Bilu Martin, MD; Premier Dermatology, MD.


Dr. Bilu Martin is in private practice at Premier Dermatology, MD, in Aventura, Fla., specializing in cosmetic, medical, and surgical dermatology. More diagnostic cases are available at To submit your case for possible publication, send an email to dermnews@


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Title Annotation:Make the Diagnosis
Author:Martin, Donna Bilu
Publication:Dermatology News
Date:Sep 1, 2016
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