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Cutaneous green and E-A-G-L-E-S!

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By Warren R. Heymann, MD
Jan. 25, 2018

Dermatologists will be seeing a lot of green in their offices the next two weeks, especially here in the Delaware Valley, in anticipation of Super Bowl LII in Minneapolis on February 4th, 2018.

May this serve as a reminder that some of the green adorning our patients may be pathologic, and possibly related to the big game itself. Advice for each circumstance is offered.

There was a lot of alcohol imbibed as the Eagles routed the Vikings 38-7, and will be even more in two weeks. If a person already has cirrhotic liver disease, or hepatic carcinoma, hyperbiliverdinemia can appear, portending a poor prognosis. Skin, sclerae, plasma, urine, and ascitic fluid may all demonstrate a greenish appearance. It has recently been demonstrated that hyperbiliverdinemia may be caused by a defect in the BVR-A gene in conjunction with decompensated liver cirrhosis. (1) Advice — go easy on the alcohol. Have light beer. Dilly dilly.

If you see green hair, don’t assume it was dyed by an Eagles fan, or in preparation for St. Patrick’s Day. Hair that turns progressively green (chlorotrichosis) may be caused by and excessive amount of dissolved copper leached from plumbing. Risk factors for chlorotrichosis include light-colored hair, copper plumbing, long periods when the water is not thoroughly flushed out of the copper pipes and frequent shampooing. It is not due to chlorine. Copper sulfate is frequently utilized in swimming pools as an algaecide. Advice — if your Super Bowl party is also a swim party, and your hair turns green, treat it with a specially compounded shampoo containing a copper-chelation agent such as penicillamine (300 mg capsule dissolved in 6 mL of water and 6 mL of shampoo) or ethylenediaminetetracetic acid. (2)

I’ll bet that tattoo parlors in Philadelphia are expanding their hours to meet the demand for Eagles tattoos emblazoned on all body parts. According to Serup: “Tattoo complications represent a broad spectrum of clinical entities and disease mechanisms. Infections are known, but chronic inflammatory reactions have hitherto been inconsistently reported and given many interpretations and terms… Allergic reactions prevalent in red tattoos and often associated with azo pigments are manifested as the ‘plaque elevation,’ ‘excessive hyperkeratosis,’ and ‘ulceronecrotic’ patterns. The allergen is a hapten. Nonallergic reactions prevalent in black tattoos and associated with carbon black are manifested as the ‘papulonodular’ pattern. Carbon black nanoparticles agglomerate in the dermis over time forming foreign bodies that elicit reactions. Many black tattoos even develop sarcoid granuloma, and the ‘papulonodular’ pattern is strongly associated with sarcoidosis affecting other organs. Tattoo complications include a large group of less frequent but nevertheless specific entities, i.e. irritant and toxic local events, photosensitivity, urticaria, eczematous rash due to soluble allergen, neurosensitivity and pain syndrome, lymphopathies, pigment diffusion or fan, scars, and other sequels of tattooing or tattoo Keratoacanthoma occurs in tattoos. Carcinoma and melanoma are rare and occur by coincidence only. Different tattoo complications require different therapeutic approaches, and precise diagnosis is thus important as a key to therapy.” (3). Reactions to green tattoos are infrequent, representing only 2% in a study of 493 complications in 405 patients. (4) Advice — if you’re performing patch testing, be aware that previously quiescent green-colored portions of tattoos may become inflamed if the patient has positive reactions to potassium dichromate. (5)

If the Super Bowl is a tight, tense affair, hyperhidrosis may ensue, leading to green chromhidrosis. Admittedly, the overwhelming number of cases will really be pseudochromhidrosis from dyes applied to the skin. Green chromhidrosis is rare, and may be due to homeopathic (or other) medications with a high cooper content (6), or hyperbilirubinemia, which may also present as green pompholyx. (7) Advice — if you know that you sweat when nervous, use the antiperspirant of your choice, consider glycopyrrolate, botulinum toxin (ahead of time), or even alprazolam!

Undoubtedly, green nail polish will be the color du jour, however, we can’t forget about the green nail syndrome due to Pseudomonas aeruginosa. These bacteria produce pyocyanin, a blue-green pigment that discolors the nail. This occurs in patients with prior nail problems, such as onychomycosis, onycholysis, trauma, chronic paronychia, or psoriasis. (8) Advice — when you’re nervous, eat nachos, not your nails!

One more thing: When the Eagles beat the Patriots (24-21, the reverse of Super Bowl XXXIX), all other NFL cities will be green with envy! Go E-A-G-L-E-S!!!

1. Gåfvels M, et al. A novel mutation in the biliverdin reductase-A gene combined with liver cirrhosis results in hyperbiliverdinemaemia (green jaundice). Liver Int 2009; 29: 1116-24.
2. Schwartz RH, et al. A teenage girl with green hair. Pediatr Dermatol 2014; 31: 497-9.
3. Serup J. How to diagnose and classify tattoo complications in the clinic: A system of distinctive patterns. Curr Prob Dermatol 2017; 52: 58-73.
4. Serup J, et al. Classification of tattoo complications in a hospital material of 493 adverse events. Dermatology 2016; 232: 668-78.
5. Jacob SE, et al. Inflammation in green (chromium) tattoos during patch testing. Dermatitis 2008; 19: E33-4.
6. Ghosh SK, et al. A curious case of blue-green discoloration in a middle-aged Indian man: Chromhidrosis. Dermatol Online J 2015; 21 (11)
7. Uzoma M, et al. Green palmoplantar vesicular eruption in a patient with hyperbilirubinemia. JAAD Case Rep 2017; 3:273-5.
8. Gish D, Romero BJ. Green fingernail. J Fam Pract 2017; 66: E7-E9.

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