Eruptive Xanthoma and Granuloma Annulare in Association with Metabolic Disorder.

Sir,

Eruptive xanthomas are benign skin lesions caused by elevated levels of serum triglycerides that leak through the capillaries and are phagocytosed by macrophages in the dermis. They typically appear suddenly as multiple erythematous-yellow, dome-shaped papules on the extensor surfaces of the extremities, buttocks, and hands.[1] On the other hand granuloma annulare (GA) is a benign, usually self-limited, granuloma to us skin disease of unknown etiopathogenesis. GA is characterized by single or multiple papules, monomorphic or pinkish, sometimes round shaped, preferably located on dorsa of the fingers, hands, and feet. Many precipitating factors of GA have been reported.[2] A well known association of GA with diabetes mellitus has been described.[2] However the relation with hyperlipidemia was recently reported in few cases.

A 43-year-old female presented with 5 months history of multiple asymptomatic yellow to skin colored papular lesions all over body. These lesions were 2–4 mm in size and symmetrically distributed over trunk, upper and lower extremities [Figure 1 a-c]. Some coalescent annular erythematous lesions were present on both the hands [Figure 2]. There was sparing of face, palm, and sole. Mucosal and nail finding were normal.

Figure 1

(a, b, c) Multiple, asymptomatic yellow to skin colored papule over buttocks, trunk and lower legs

Figure 2

Skin color coalescent annular erythematous lesions present over both hands

Laboratory investigations revealed hypertriglyceredemia and hypercholesterolemia (triglycerides 4594 mg/dl, total cholesterol 857 mg/dl, VLDL cholesterol 918 mg/dl). Blood glucose levels (fasting 142 mg/dl, postprandial 300 mg/dl) were also raised. There was no history of dyslipidemia and diabetes mellitus in family. The general physical, cardiovascular, and ophthalmological examinations were normal.

Histopathological examination from papular lesion on back revealed diffuse sheets of foamy histiocytes in reticular dermis and few perivascular mononuclear inflammatory cells infiltration [Figure 3]. Biopsy from annular lesion of left hand revealed multiple granulomas, composed of central feathery blue mucinous material surrounded by epithelioid cells, and lymphoid cells [Figure 4]. Mucin stain was also positive.

Figure 3

Eruptive xathoma (H and E). Biopsy section (×10) revealed diffuse sheets of foamy histiocytes in reticular dermis and few perivascular mononuclear inflammatory cells infiltration

Figure 4

Granuloma annulare. Biopsy section (×10) revealed multiple granulomas, central feathery blue mucinous material surrounded by epitheloid cells, lymphoid cells

Based on the clinical history with laboratory values and histopathological examinations, the diagnosis of eruptive xanthoma with granuloma annulare was made. Patient was started on atorvastatin and fenofibrate in addition to glimepride and metformin. After two months of treatment, xanthoma lesions completely cleared with partial resolution of GA lesions [Figure 5 a-d] and decrease in laboratory values (Total cholesterol 185mg/dl, triglyceride 261 mg/dl, VLDL cholesterol 52mg/dl, random blood glucose 156 mg/dl).

Figure 5

Clinical pictures of both xanthoma (a-c) and granuloma annulare (d) after 2 months of treatment

Eruptive xanthoma and granuloma annulare are clinically different dermatoses. Eruptive xanthomas are characterized by the sudden appearance of grouped, yellow-red papules scattered over the trunk, arms, legs and buttocks. The condition is associated with markedly elevated trigyceride levels, with reported prevalence of 10% in published literature.[3]

Annular GA lesions were composed of individual coalescing papules arranged in a ring like or circinate configuration.[4] In a study of 100 patients with generalized GA, reported percentages of hypercholesterolemia and hypertriglyceridemia was 19.6% and 23.3%, respectively. The study showed a higher prevalence of elevated serum lipid levels in the annular rather than nonannular GA subgroups.[4]

There is a large correlation with newly diagnosed diabetes mellitus and eruptive xanthoma and GA; the explanation is that insulin and hyperlipidemia are stimulating factor. Association of dyslipidemia with eruptive xanthoma is well documented but it has been recently reported with granuloma annulare.[5] Adequate treatment involves controlling the underlying hyperlipidemia and diabetes mellitus. Once lipid levels normalized, graded resolution of cutaneous lesions in typically observed as seen in our patient too.

To conclude, our case showed an association between granuloma annulare and eruptive xanthoma. The presence of generalized GA and/orannular lesion morphology should trigger a high index of suspicion for dyslipidemia. Clinicians should be aware of these associations and consider them in the management of GA and xanthoma.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.