Dermatology Online Journal

Granuloma faciale with disseminated extra facial lesions
Soheila Nasiri MD, Hoda Rahimi MD, Ali Farnaghi MD, Zahra Asadi-Kani MD
Dermatology Online Journal 16 (6): 5

Skin Research Center, Shahid Beheshti Medical University, Tehran, Iran. hoda_rahimi@yahoo.com

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Abstract

Granuloma faciale (GF) is a rare cutaneous disorder categorized as a localized form of small vessel vasculitis. Clinically, it manifests as single or multiple, well-demarcated, red-brown plaques, papules and nodules, nearly always confined to the face. Herein, we report a 39-year-old man with multiple red-brown, infiltrated plaques on his face and extrafacial lesions on the back, shoulders, and both arms. Skin biopsy revealed typical histopathological findings of GF. The patient failed to respond to pulsed dye laser, but intralesional triamcinolone combined with cryotherapy led to an acceptable response.

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Introduction

Granuloma faciale (GF) is a rare cutaneous disorder categorized as a localized form of small vessel vasculitis. Clinically, it manifests as single or multiple erythematous to livid papules, plaques, or nodules that usually occur on the face, often with follicular accentuation [1]. The lesions are usually asymptomatic but may be associated with mild pruritus. The sites of predilection are the sides of the nose (30%), tip of the nose (7%), preauricular area (22%), cheeks (22%), forehead (15%), and helix of the ear (4%) [2]. Disseminated or extrafacial GF has been reported but is very rare [3-8].

Case report

Figure 1
Figure 1. Facial red-brown papule in a patient with disseminated granuloma faciale

A 39-year-old man presented to our clinic with several persistent mildly pruritic plaques over his forehead, shoulders, both arms, and back for almost 1 year. The initial lesion had developed on the back, but he progressively developed additional involvement of the shoulders, arms, and at last, face. He had no significant past medical history.

On examination, there were red-brown, 0.5–3 cm sized, well-demarcated and slightly indurated papules and plaques over the face (Figure 1), back (Figures 2 and 3), shoulders, and arms. The follicular openings over some lesions were accentuated (Figure 1). General physical examination was normal.

Figure 2	Figure 3
Figures 2 and 3. Disseminated red-brown plaques on the back

Routine laboratory tests were unremarkable. We performed two 5 mm punch biopsies, from the face and trunk. Histopathologic examination of both biopsy specimens revealed a normal epidermis with a narrow grenz zone (Figure 4) in the subepidermal portion, associated with infiltration of mixed inflammatory cells, including lymphocytes and many eosinophils. There was nuclear dust around vessels with partially occluded lumens and prominent endothelial cells, thereby confirming the diagnosis of granuloma faciale (Figure 5).

Figure 4	Figure 5
Figure 4. Histopathologic examination of the truncal lesion: normal epidermis with narrow grenz zone in subepidermal portion associated with infiltration of mixed inflammatory cells, including many eosinophils (H&E, x10). Figure 5. Histopathologic examination of the truncal lesion: infiltration of mixed inflammatory cells, including lymphocytes, some nuclear dusts and many eosinophils around vessels with prominent endothelial cells and fibrinoid necrosis (H&E, x40).

Initially, the patient was treated with pulsed dye laser (585 nm) for two sessions but no response was observed. Then, cryotherapy in combination with intralesional triamcinolone acetonide (5 mg/ml) was initiated. This treatment was repeated every 4 weeks for three courses, resulting in an acceptable response.

Discussion

Granuloma faciale is characterized by one to several soft, erythematous to livid papules, plaques, or nodules with follicular accentuation. It is often a disorder of middle-aged white men, but it can occur at any age and sex [3]. The typical lesion of granuloma faciale is a solitary plaque on the face [4]. Extrafacial involvement is rare and has been reported to involve the back, arms, chest, shoulders, and thighs [5, 6, 7, 8]. Our case had involvement of the back, shoulders, and arms in addition to typical facial lesions. The predominance of extrafacial lesions that appeared some months prior to facial ones in our patient was quite striking and has been reported only once before [8].

Granuloma faciale has distinctive clinical characteristics but erythema elevatum diutinum, sarcoidosis, lymphoma, lupus, and basal cell carcinoma are the main conditions in the differential diagnoses [9].

Granuloma faciale is resistant to treatment. Many different medical therapies, including topical or intralesional corticosteroids, antimalarials [10], dapsone, clofazamine, isoniazide, and topical tacrolimus [11], have been tried with various results. A variety of surgical procedures such as surgical excision [12], dermabrasion, argon laser, carbon dioxide laser, pulsed dye laser [13], electrosurgery, and cryotherapy have also been used for the management of GF. A combination of intralesional corticosteroid and cryotherapy was also reported to be effective [8, 14]; this had an acceptable result in our patient.

References

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