HistoryThis section has been translated automatically.
Colcott-Fox 1895; Wigley 1945; Pedace and Perry 1966
DefinitionThis section has been translated automatically.
Rare, chronic, usually benign, inflammatory skin disease(dermatologically accentuated systemic disease) of unknown etiology, with a distinct clinical (in an early stage peau d`orange aspect of the surface) and histologic aspect, characterized in an early stage by a histoeosinophilia, although inconstant, but usually formative, as well as signs of a leukocytoclastic vasculitis. This early inflammation is overlaid over time by increasing fibrosis, clinically recognizable by a consistency proliferation of plaques (nodules).
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Occurrence/EpidemiologyThis section has been translated automatically.
Rare! In large dermatological centers this diagnosis is made 1-2x per year.
Preferably in whites.
Men are significantly more often affected than women. In one "medium-sized" study (n=11) the ratio was about 80%, in another 60% in favor of men.
EtiopathogenesisThis section has been translated automatically.
Ultimately unknown. In the past, the disease was (erroneously) classified as a granulomatous disease. However, the vasculitic phenomena with leukocytoclasia, which can be detected in the early stage of the disease by fine tissue analysis, rather point to a vasculitic genesis.
The concordant occurrence with sino-nasal localized eosinophilic angiocentric fibrosis suggests a close pathogenetic relationship of both diseases (see below). It is increasingly considered to classify granuloma faciale as a cutaneous manifestation of an IgG4-associated disease.
Associated infections (streptococcal infections, syphilis, viral infections -hepatitis virus, HIV, tumor diseases (prostate carcinoma, lymphoma, multiple myeloma etc.) as well as autoimmune diseases (rheumatoid arthritis, celiac disease, Crohn's disease, uveitis) have been observed.
ManifestationThis section has been translated automatically.
Possible at any age, preferentially affecting adults between 40-60 years of age; less commonly, children may also be affected.
LocalizationThis section has been translated automatically.
V.a. face, preferentially on nose, chin, forehead, temples and cheeks, also on capillitium.
About 10-20% of cases are extrafacial: upper and lower extremities, capillitium, trunk (see Fign.).
Involvement of the oral mucosa is rare (see also the rhino-nasal involvement pattern of eosinophilic angiocentric fibrosis.
Clinical featuresThis section has been translated automatically.
Roundish to oval, 0.5-2.0 cm in size, usually solitary but also several or numerous, slightly raised, firm, asymptomatic, red or brown-red, with longer persistence also brown-yellowish, scale-free plaques with dilated follicular orifices. This results in an "orange peel-like" surface aspect at an early stage of the disease. This is no longer detectable in later, long-term plaques or nodules. In these cases, a surface smooth, follicle-free surface relief may present. Occasionally, more severe fibrosis is also observed, so that keloid-like nodular structures may appear (Verma R et al. 2005).
Rare are large-area, 5.0- 7.0 cm, bizarrely configured, firm plaques that prove markedly resistant to therapy. Diascopically, a yellow-brownish intrinsic infiltrate is characteristic. The rare coincidental occurrence with other (IgG4-associated) diseases is possible:
- Eosinophilic angiocentric fibrosis: Inflammatory pseudotumorous mucosal affection interpreted as a monotopic sinonasal variant of IgG4-associated autoimmune disease. Since it can occur coincidentally with granuloma faciale, a close pathogenetic association of both entities can be assumed especially since their histologic substrate has a high degree of commonality.
- Retroperitoneal fibrosis
In very rare cases, granuloma faciale has been implicated as a precursor of severe vasculitides such as:
HistologyThis section has been translated automatically.
In the early stage, the signs of leukocytoclastic vasculitis can be detected with perivascular oriented neutrophilic granulocytes and nuclear dust and fibrin in the vessel walls. Eosinophilic leukocytes are encountered to varying degrees. Fibrinoid vascular occlusions are also observed in early phases.
In clinically "full-blown" lesions, a dense, diffuse infiltrate is found in the upper and middle dermis. Vascular orientation is usually not (or no longer) detectable. Epidermis and skin appendages remain uninvolved. The infiltrate-free border strip is typical. The infiltrate consists of lymphocytes, neutrophilic leukocytes and nuclear dust, eosinophilic leukocytes, histiocytes and plasma cells. In addition, proliferation of fibrocytes.
Late stage onion-skin-like fibrosis may impose; storiform patterns are also possible. Eosinophilia is largely absent. An accentuated plasma cellular component is often found. Occasionally, granulomatous tissue reaction with histiocyte- and granulocyte-rich infiltrates is also observed.
Schematizingly, the following algorithm can be established:
|Accentuated around postcapillary venules|
|capillaries left out of the less involved|
|Damage to endothelial cells|
|Fibrin in/in the area of vessel walls|
|perivascular extravasation of erythrocytes|
|Edema in the papillary dermis|
|Variable number of eosinophils|
|Plasma cells and fibrosclerosis|
Direct ImmunofluorescenceThis section has been translated automatically.
No groundbreaking fluorescence pattern. Deposits of immunoglobulins (especially IgG), complement (C3/C4) and fibrinogen were detected at the dermo-epidermal junction zone, but in the vessel walls and around vessels of the middle dermis.
Differential diagnosisThis section has been translated automatically.
- Drug reaction, fixed: Rarely occurring in the facial region; short history; succulent foci without follicular accentuation; tendency to blister.
- Lymphadenosis cutis benigna: Clinically and anamnestically very similar; almost always solitary; follicular accentuation is possible; color is not red but brown; diascopic: intrinsic infiltrate.
- B-cell lymphoma of the skin (see primary cutaneous B-cell lymphoma)
- Lupus erythematosus (CDLE): Usually years-long disease career, atrophic surface epithelium; scarring in older foci; painful when brushed with fingernail. Histology and IF are diagnostic.
- Sarcoidosis: Brown plaques with smooth surface; no follicular emphasis; usually multiple. Histology definitely excludes granuloma eosinophilicum faciei.
- Tuberculosis cutis luposa: Rare at capillitium; acral localization is typical; atrophic surface epithelium, no follicular accentuation; brown-red color, typical yellow-brown intrinsic filtrate.
- Erythema elevatum diutinum: Rare; usually extensor on the extremities; rarely occurring on the face; polycyclic, nodular, blue-red or red-brown, succulent, extensive plaques. Possible stabbing pain, burning and itching.
Histological differential diagnoses:
- Leukocytoclastic vasculitis of other etiology: Mostly vigorouserythrocyte extravasation; no prominent eosinophilia; infiltrate is overall less marked.
- Erythema elevatum diutinum: Considered by some authors to be a variant of granuloma (eosinophilicum) faciei. Histologically indistinguishable.
- Eosinophilic cellulitis (Wells syndrome): Dense, perivascular and interstitial infiltrates; almost exclusively eosinophilic and (few) neutrophilic granulocytes. Polygonally circumscribed, eosinophilic flame figures in the dermis. No signs of vasculitis.
- Lymphadenosis cutis benigna (cutaneous pseudolymphoma): Dense mature-cell dermal infiltrate of lymphocytes, plasma cells, reticulum cells; only occasional eosinophilic leukocytes. Formation of lymphoid follicles with germinal center cells. No signs of vasculitis.
TherapyThis section has been translated automatically.
Because of benignity and chronicity of the disease, the therapeutic risk should be weighed. Therapy trial with DADPS (e.g. dapsone fatol): 100-200 mg/day for 4 months (therapy success only moderate!). Caveat. Determine glucose-6-phosphate dehydrogenase before starting therapy. If necessary, intralesional glucocorticoid injection with triamcinolone acetonide crystal suspension(Volon A 10 mg, diluted 1:3-1:5 with local anesthetics, e.g. scandicaine).
Positive therapeutic effects (single case reports) have been reported with locally applied tacrolimus or pimecrolimus (occlusive at times) and topical dapsone (Topical Dapsone as 5% Gel/Aczone; Allergan Inc, Irvine, CA) (Lindhaus C et al. 2018).
The rare large-area or large-nodule variants of granuloma faciale can persist for years, growing slowly. They prove to be markedly resistant to therapy. In these cases, irradiation with fast electrons is an alternative.
Progression/forecastThis section has been translated automatically.
Chronic course, spontaneous healing under scarring atrophy is possible especially in infantile granuloma faciale.
Note(s)This section has been translated automatically.
There is a close etiopathogenetic relationship to erythema elevatum diutinum. Both cases are vasculitic processes. The histological substrate (factor: eosinophilia) is decisive for differential diagnosis. The clinical aspect of the punctate surface (orange peel-like) arises from the pressure of the dermal infiltrate. This leads to an interfollicular protrusion of the surface. With simultaneous preservation of the follicle, it pulls inward like a wick, resulting in these "follicular impressions." Important differential diagnostic feature to differentiate from malignant (follicle-destroying) processes.
However, tissue eosinophilia is not a constant feature of granuloma (eosinophilicum) faciale. While it is often predominant in the early phase of granuloma faciale, it may be completely absent in the late stage in favor of a plasma cell component.
Additionally, and thus misleadingly, the term "eosinophilic granuloma" is occupied by a variant of Langerhans cell histiocytosis. To avoid this misunderstanding, the term"granuloma faciale" is increasingly used, alternatively granuloma faciale with eosinophilia.
LiteratureThis section has been translated automatically.
- Barnadas MA et al (2006) Direct immunofluorescence in granuloma faciale: a case report and review of literature. J Cutan Pathol33:508-511
- Bonet J et al (2001) Eosinophilic granuloma of the jaws: a report of three cases. Med Oral 6: 218-224
- Deen J et al (2017) Extrafacial granuloma faciale: a case report and brief review. Case Rep Dermatol 9:79-85.
- Lazarov A et al. (2003) Contact orofacial granulomatosis caused by delayed hypersensitivity to gold and mercury.J Am Acad Dermatol 49: 1117-1120.
- Lindhaus C et al.(2018) Granuloma faciale treatment: A systematic review. Acta Derm Venereol 98:14-18.
- Ludwig E et al (2003) New treatment modalities for granuloma faciale. Br J Dermatol 149: 634-637.
- Madan V (2011) Recurrent granuloma faciale successfully treated with the carbon dioxide laser. J Cutan Aesthet Surg 4:156-157
- Mahmood F et al (2022) A rare case of granuloma faciale presenting with ulceration: A case report. SAGE Open Med Case Rep10:2050313X221093150.
- Micallef D et al (2017) Complete Clearance of Resistant Granuloma Faciale With Pulsed Dye Laser After Pre-treatment With Mometasone and Tacrolimus. J Lasers Med Sci 8:95-97.
- Müller CSL et al (2016) Diagnostic and histologic features of cutaneous vasculitides/vasculopathies. Act Dermatol 42: 286-301
- Nayak NV et al (2014) Postirradiation periocular granuloma faciale associated with uveitis. Ophthal Plast Reconstr Surg 30:e92-95.
- Nogueira A et al (2011) Granuloma faciale with subglottic eosinophilic angiocentric fibrosis: case report and review of the literature. Cutis 88:77-82
- Ortonne N et al (2005) Granuloma faciale: a clinicopathologic study of 66 patients. J Am Acad Dermatol 53:1002-1009.
- Ratzinger G et al (2015) The vasculitis wheel-an algorithmic approach to cutaneous vasculitides. JDDG 1092-1118
- Rieker J et al (2006) Multifocal granuloma eosinophilicum faciei. Successful treatment with topical tacrolimus. Dermatologist 57: 324-326
- Rütten A et al (2007) Extrafacial granuloma eosinophilicum. Dermatologist 58: 435-439
- Singh SK et al (2013) A rare case of keloidal granuloma faciale with extra-facial lesions. Indian Dermatol Online J 4:27-29.
- Taylor G et al (1994) Granuloma faciale successfully treated with the argon laser - a case report. Eur J Dermatol 4: 623-624.
- Tojo G et al (2012) Successful treatment of granuloma faciale with topical tacrolimus: a case report and immunohistochemical study. Case Rep Dermatol 4:158-162
- Vassallo C et al (2015) Chronic localized leukocytoclastic vasculitis: clinicopathological spectrum of granuloma faciale with and without extrafacial and mucosal involvement. G Ital Dermatol Venereol 150:87-94
- Verma R et al (2005) Keloidal granuloma faciale with extrafacial lesions. Indian J Dermatol Venereol Leprol 71:345-347.
- Wigley JEM (1945) Sarcoid of Boeck? Eosinophilic granuloma. Br J Dermatol 57: 68-69.
Incoming links (18)Angiolupoid; Dadps; Eosinophilia and skin; Eosinophilic angiocentric fibrosis; Erythema elevatum diutinum; Facial granuloma eosinophilicum; Granuloma eosinophiles of the face; Granuloma eosinophilicum faciei; Granuloma of the face eosinophil; Granuloma, ulcerating eosinophils of the mucous membrane; ... Show all
Outgoing links (27)Argon laser; Borrelia lymphocytoma; Cauterization; Co2 laser; Cryosurgery; Dadps; Dermabrasion; Drug reaction fixe; Eosinophilia and skin; Eosinophilic angiocentric fibrosis; ... Show all
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