Granuloma faciale.

Sir,

Granuloma faciale is a rare benign chronic inflammatory dermatosis of unknown etiology, which manifests as asymptomatic red-brown nodules or plaques usually confined to face.[1] Diagnosis is based on clinical features and histopathology. Recently, dermatoscopy is also useful as a diagnostic aid.

We describe a case of a 23-year-old woman who came with complaints of two asymptomatic red lesions over face since 3 months with no history of increase in size of lesions. On examination, there was evidence of two nontender erythematous papulo-nodules each on left temple and right cheek [Figure 1a and b]. There was no evidence of enlarged nerves or loss of sensations or presence of any hypopigmented patch elsewhere over the body. There was no history of trauma or any medical or surgical illness. Family history was not significant. Dermoscopy could not be done due to unavailability. An excision biopsy was taken from the lesion over the left temple, which on histopathology showed presence of Grenz zone [Figure 2a] and dense mixed infiltration mainly consisting of eosinophils throughout the dermis with evidence of onion peel appearance of arterioles, suggestive of vasculitis [Figure 2b and c]. The patient was given three sittings of intralesional steroids at an interval of three weeks with no improvement. Later, she was advised to apply topical tacrolimus ointment (0.1%) for one month leading to reduction in size of the lesion, which was finally excised. The patient was followed up for five months with no history of recurrence.

Figure 1

(a) Evidence of an erythematous nodule with follicular accentuation on left temple. (b) Evidence of an erythematous nodule on right cheek

Figure 2

(a) Evidence of a Grenz zone just beneath the epidermis as seen under low-power magnification. (b) Evidence of dense polymorphous infiltration in the dermis along with onion peel appearance of arterioles suggestive of vasculitis as seen under low-power magnification. (c) Predominance of eosinophils in the dermis as seen under high-power magnification. The stain used is haematoxylin and eosin stain. Low power is x10 and high power is x40

The term granuloma faciale was originally described by Wigley in 1945 as eosinophilic granuloma of the skin, further defined by Pinkus.[2] It mainly affects middle-aged white men between third and fifth decade. The etiology is usually unknown. Clinically, the lesions appear as asymptomatic well-circumscribed smooth erythematous papules, nodules, or plaques with follicular accentuation on sun-exposed sites. Majority of the lesions are confined to face with rare involvement of extra facial sites such as back, arms, chest, shoulders, and thighs.

The disease runs a chronic course without any systemic involvement. The main clinical differential diagnoses include leprosy, erythema elevatum diutinum, sarcoidosis, cutaneous lymphomas, pseudolymphoma, discoid lupus erythematosus, basal cell carcinoma, lymphocytic infiltrate of Jessner, and lupus vulgaris.[3]

Dermoscopy of the lesions may show a translucent white gray background intermingled with orthogonal whitish streaks and elongated telangiectasias, which can also be seen in discoid lupus erythematosus, sarcoidosis, and lupus vulgaris.[4] Hence, a skin biopsy is required to confirm the diagnosis. The term granuloma faciale is a misnomer because the histological appearance does not demonstrate granulomatous inflammation. The unaffected epidermis is separated from the affected dermis by a Grenz zone of normal dermal collagen with underlying polymorphous dense dermal infiltrate consisting mainly of eosinophils and features of vasculitis.[5] Granuloma faciale is usually refractory to treatment. Multiple treatment modalities such as topical and intralesional corticosteroids, topical tacrolimus, colchicine, dapsone, antimalarials, surgical procedures such as surgical excision, dermabrasion, argon laser, carbon dioxide laser, pulsed dye laser, electrosurgery and cryotherapy have been tried with variable success.[23]

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Conflicts of interest

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