Dermoscopy of Granuloma Faciale in the Skin of Color

A 55-year-old male presented with a single raised lesion over face for 2 months. There were no associated complaints. On examination, a single erythematous papule, of 0.5 × 0.5 cm, without any surface changes, was present over the center of the left cheek [Figure 1]. Dermoscopic examination (DermLite DL4, 3Gen, San Juan Capistrano, CA, USA, ×10, polarized non-contact mode, images captured with dermlite adaptor for iPhone X) was done, which revealed patulous follicular openings seen as yellow dots, linear yellow-white streaks, along with multiple linear vessels with branches over a diffuse reddish-orange background [Figure 2]. Histopathological examination was done with clinical differentials of granuloma faciale (GF), lupus vulgaris, sarcoidosis, and pseudolymphoma. Histopathological examination revealed a grenz zone, and dense polymorphous infiltrate in the dermis comprising of neutrophils, eosinophils, lymphocytes, histiocytes, and plasma cells. The dermal blood vessels were dilated with swollen endothelial cells, infiltration of the vessel wall with inflammatory infiltrate and leukocytoclasia [Figure 3a-c]. A final diagnosis of GF was made.

Figure 1.

Solitary, erythematous papule with normal overlying skin over the center of left cheek

Figure 2.

Dermoscopic examination showing yellow dots (blue circle), linear yellow-white streaks (blue arrow), and linear branched vessels (black arrow) over a diffuse reddish-orange background. (DermLite DL4, 3 Gen, San Juan Capistrano, CA, USA, ×10, polarized non-contact mode)

Figure 3.

(a) Histopathologic examination showing grenz zone with dense polymorphous infiltrate in the dermis (H and E, 10×); (b) higher power shows mixed infiltrate comprising eosinophils, neutrophils, lymphocytes, histiocytes, plasma cells, with dilation of vessels and endothelial cell swelling (H and E, 40×); (c) vessel wall infiltration with acute inflammatory cells and leukocytoclasia seen (H and E, 40×)

Granuloma faciale (GF) is a chronic, rare disease of unknown origin, which characteristically presents in middle-aged male patients.[1] The diagnosis is usually made on clinical grounds and confirmed on histology. Recently, dermoscopy has come up as a useful tool in furthering the diagnosis of non-neoplastic disorders. Dermoscopy of GF has previously revealed dilated follicular openings, linear vessels, brown dots/globules over a red to yellow-brown background. [1,2] In the present case, dermoscopy helped to appreciate the findings of dilated follicular openings and telangiectasia, which were inconspicuous during the patient’s clinical examination and were seen dermoscopically as yellow dots and linear branched vessels. The dermoscopic findings of reddish-orange background and yellow-white streaks could be secondary to the mass effect by the underlying dense dermal infiltrate and alteration in collagen orientation caused by dense dermal infiltrate, respectively. Dermoscopy in the present case did not show brown dots, which can be explained by the relatively short duration of the disease and, the absence of hemosiderin deposition, believed to be the reason for this. The dermoscopic appearance of well-focussed vessels over an orangish background is not unique to GF and is seen in several disorders including sarcoidosis, infections like lupus vulgaris, and pseudolymphoma.[3] However, patulous follicular openings visualized as yellow dots in the present case should raise a suspicion of GF when present, along with well-focused vessels over an orangish background. Dermoscopy of differential diagnosis of GF is summarized in Table 1. GF is a rare disorder with only a handful of reports describing the dermoscopic findings in the literature and none in the Asian population. Further studies with a larger number of patients are needed to corroborate the findings of the present case.

Table 1.

Dermoscopy findings of differentials of granuloma faciale

Disorder	Dermoscopic finding
Sarcoidosis[4]	Structureless orange globules with linear and branching vessels, white scar-like areas
Lupus vulgaris[3]	Focal or diffuse yellowish-orange structureless areas with well-focused vessels. Pigmentation structures, milia-like cyst, whitish reticular streaks, prominent epidermal changes like scaling and crusting can also be seen
Cutaneous pseudolymphoma[5]	Pinkish background, white reticular lines Some fine linear vessels across white reticular lines
Present case	Patulous follicular openings seen as yellow dots, linear yellow-white streaks, along with multiple linear vessels with branches over a reddish-orange background

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.