Received: 9 October 2022 Accepted: 8 January 2023
DOI: 10.1111/ddg.15012
O P E R AT I V E T E C H N I Q U E
Surgical extraction of an omphalolith in a non-obese adult
Woo Chiao Tay Benjamin Wen Yang Ho
National Skin Centre, Singapore
Correspondence
Woo Chiao Tay, MBBS, National Skin Centre, 1 Mandalay Road, Singapore 308205.
Email: woochiao.tay@mohh.com.sg
A male patient in his 60s presented with an incidental
growth on his umbilicus for six months. There was no asso-
ciated pain, itch, or any systemic symptoms. He was not
overweight and had no other significant medical history.
Examination (with the umbilicus everted and the nod-
ule held with toothed forceps) revealed a sub-centimeter
hyperkeratotic crusted nodule arising from his umbilicus
(Figure 1a). The clinical diagnosis of omphalolith was made.
A home trial of olive oil soaks to soften the nodule was
started but it was not effective. Elective excisional biopsy
of the nodule was scheduled a week later.
We used the “paraffin oil sign” to confirm our diagnosis
and facilitate the removal of the nodule. Pre-operatively, the
nodule was first immersed in liquid paraffin and occluded
with a paraffin-soaked gauze for 20 minutes (Video 1,
online supplementary video). The liquid paraffin oil used
was kept at standard room temperature, usually set at 22–
24◦ C in the operating theatre. Careful extraction of the
superficial part of the nodule was done using surgical for-
ceps (Figure 1b). The remaining debris in the umbilicus
was carefully debrided using a blunt curette and cotton
F I G U R E 1 (a) A firm, hyperkeratotic nodule
arising from the umbilicus and (b) after its
removal.
© 2023 Deutsche Dermatologische Gesellschaft (DDG).
JDDG: Journal der Deutschen Dermatologischen Gesellschaft. 2023;21:553–554.
Wei-Sheng Chong Suzanne Wei Na Cheng
tip to avoid epidermal trauma. Intra-operative examination
revealed that the patient had a deep but narrow umbilicus,
which made debridement more challenging. (Figure 2) His-
tology of the nodule showed compact lamellated keratin
with aggregates of gram-positive bacteria, suggestive of a
keratinaceous plug, consistent with an omphalolith.
Omphalolith, also known as umbilical concretion, is a rare
but benign condition caused by the accumulation of ker-
atinaceous material in the umbilicus. Less than 40 cases
worldwide have been reported in the English literature. The
common risk factors are obesity, elderly women, patients
with anatomically deep and narrow umbilicus, or reduced
ability for self-care or poor umbilical hygiene predispos-
ing to accretion of keratinaceous debris.1 Interestingly, a
local myth amongst elderly Japanese that cleansing of the
“umbilical sesame” causes abdominal pain has been pos-
tulated to cause a greater than expected frequency of
omphalolith in that population.2
Prolonged pressure on an omphalolith from the sur-
rounding tissues in the umbilicus compresses the nodule
compactly, leading to its presentation as a firm dark-black
wileyonlinelibrary.com/journal/ddg 553

554
F I G U R E 2 The omphalolith was removed with minimal epidermal
breach. The debris in the umbilicus was debrided completely.
nodule. It is usually asymptomatic, but irritated lesions can
cause itch, erosion, bleeding, fistulation, superficial and
deep infection including abscess and peritonitis.1,3 Two
patients with underlying pyogenic granuloma have been
reported as well.1
Diagnosis of omphalolith can be made clinically. Der-
matoscopy shows non-specific aggregates of pigmented
keratinaceous material. Histology classically shows com-
pact lamellated keratin, collections of amorphous material
containing sebum, terminal hair, or aggregates of bac-
teria. Imaging modalities such as ultrasonogram, CT or
MRI scans may be considered for equivocal presentations.
While the condition is benign, important differential diag-
noses to exclude are Sister Mary Joseph’s nodule, malignant
melanoma, squamous cell carcinoma and primary umbilical
malignancy.
For treatment, the extraction of asymptomatic
omphaloliths can be performed with careful removal using
surgical forceps. In our patient, this was easily achieved
after the nodule had been immersed in liquid paraffin for 20
minutes to soften the keratinaceous top. We propose this as
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OPERATIVE TECHNIQUE
a positive “paraffin oil sign”, differentiating an omphalolith
from the other differential diagnoses. Alternatively, the
use of glycerin, olive oil or saline has also been reported.1
Depending on the depth of involvement and presence of
complications such as abscesses or peritonitis, there are
reports of omphalolith removal under local anesthesia,
under regional spinal anesthesia with an elliptical incision
around the umbilicus, and under general anesthesia with
laparoscopic examination and excision of fistulous tracts.3,5
The umbilicus may have to be excised in recalcitrant cases.4
Reducing modifiable risk factors such as improving umbil-
ical hygiene and weight loss are adjunctive measures to
lower its recurrence.
Omphalolith is a rare but benign condition. However,
it has the potential to cause severe complications if not
treated early. We suggest the use of liquid paraffin immer-
sion for at least 20 minutes to facilitate the careful removal
of early omphaloliths at the bedside.
CONFLIC T OF INTEREST
None.
REFERENCES
1. Soriano LF, Pathmarajah P, Rajpopat S, Sahota A. Omphaloliths: A
case series and review of 29 cases in literature. Dermatol Online J.
2019;25(9):13030/qt1pj5r7s7.
2. Ichiki Y, Kitajima Y. Omphalith. Clin Exp Dermatol. 2009;34(3):420-421.
3. Mahdi HR, El Hennawy HM. Omphalolith presented with peritonitis: A
case report. Cases J. 2009;2(8):1-3.
4. Gallouj S, Harmouch T, Amarti A, Fatima Z. Omphalolith: a rare entity
but important to recognize. Dermatol Online J. 2014;20(5):22641.
5. Kumar SKL, Reddy CO, Reddy K. Omphalolith. Indian J Surg.
2011;73(3):238-239.
S U P P O R T I N G I N F O R M AT I O N
Additional supporting information can be found online in
the Supporting Information section at the end of this article.
How to cite this article: Tay WC, Ho BWY, Chong
W-S, Cheng SWN. Surgical extraction of an
omphalolith in a non-obese adult. JDDG: Journal der
Deutschen Dermatologischen Gesellschaft.
2023;21:553–554.
https://doi.org/10.1111/ddg.15012