Granuloma faciale: An unusual diascopic finding

Abstract

Granuloma faciale (GF) is a benign, chronic inflammatory disorder, characterized by reddish brown plaques with prominent follicular orificesand telangeictasia, usually occurring over the face. The condition often presents a problem in differential diagnosis. Herein we describe a case of GF with an unusual diascopic finding of an apple jelly appearance on diascopy.

INTRODUCTION

Granuloma faciale (GF) is a rare disease characterized by asymptomatic cutaneous reddish brown papules, nodules, and plaques on the face, with prominent follicular openings often confused with cutaneous sarcoidosis and discoid lupus erythematosus.[1] It is a misnomer both clinically and histologically, as lesions occasionally can be present on the extrafacial sites, and granulomas are not seen on histology.[2]

We herein report a case of GF, with an unusual clinical finding of apple jelly appearance on diascopy, which is not a known feature of nongranulomatous disorders.

CASE REPORT

A 40-year-old woman presented with an asymptomatic, gradually progressive erythematous plaque on her right cheek since one year. There was no history of trauma prior to onset of the lesion. Dermatological examination revealed a solitary, well-defined, annular, erythematous plaque on the right cheek measuring 5 cm, with a few satellite papules. Surface showed prominent follicular orifices and telangiectasia [Figure 1]. It was firm in consistency with no feeding nerves or loss of sensation. Apple jelly nodules were demonstrated on diascopy [Figure 2]. The differentials of annular cutaneous sarcoidosis and lupus vulgaris were considered. Biopsy from the active margin revealed a subepidermal Grenz zone and nodular mixed inflammatory infiltrate composed predominantly of neutrophils, eosinophils and a few lymphocytes and extravasated RBCs, consistent with granuloma faciale [Figure 3a and 3b]. She was treated with intralesional triamcinolone acetonide and topical tacrolimus ointment 0.03% twice daily. Complete regression of the lesion was seen after two months [Figure 4].

Figure 1.

An annular plaque over right cheek with prominent follicular orifices

Figure 2.

Apple jelly nodules on diascopy

Figure 3.

(a) Normal epidermis with a subepidermal Grenz zone and nodular inflammatory infiltrate in the upper dermis. (H and E, ×10). (b) Showing mixed dermal inflammatory infiltrate composed of neutrophils, eosinophils, and lymphocytes with extravasated RBCs. (H and E, ×40)

Figure 4.

Complete regression of the lesion after 2 months of treatment

DISCUSSION

GF was first described by the term eosinophilic granuloma of the skin by Wigley.[3] It was later renamed as granuloma faciale by Pinkus in 1952.[4] Although the etiology is unknown, it is considered to be a localized chronic fibrosing vasculitis and is characterized by solitary or multiple, reddish brown to voilaceous plaques on the face with prominent follicular openings. Occasionally there is involvement of extrafacial sites such as trunk, extremities, and scalp. Clinical differential diagnoses include sarcoidosis, lymphoma and pseudolymphoma, granulomatous variant of rosasea, leprosy, and tumid lesions of discoid lupus erythematosus. Histologically, apart from typical features mentioned above, extravasated erythrocytes with deposits of hemosiderin may be seen that clinically correlate with the brownish color of the lesions.[1]

Our patient presented with classical clinical features of GF and interestingly, on diascopy apple jelly nodules were observed.

Apple jelly nodule was first described by Jonathan Hutchinson.[5] It is the term used to describe the elementary lesion of lupus, to depict the papules found in plaques of lupus vulgaris which, especially under diascopy, has a yellowish brown shade of color, that is reminiscent of apple jelly.[6] It is considered to represent the collection of tubercles in the dermis with degenerative changes.[7] Although highly characteristic of lupus vulgaris, it is not pathognomonic as other chronic granulomatous disorders of skin such as lupoid leishmaniasis, sarcoidosis, lupoid rosasea, pseudolymphoma may also give similar appearance on diascopy.[8]

The highlight of this case report is the appearance of apple jelly nodules on diascopy in a case GF. This unusual clinical finding to the best of our knowledge has not been reported so far in the literature. The probable reason for the appearance of apple jelly nodule in our case may be the prominent nodular collection of mixed inflammatory infiltrate in the dermis with extravasation of RBCs.

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.

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Conflicts of interest

There are no conflicts of interest.