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Granulomatous Facial Dermatitis - Symptoms, Diagnosis and Treatment

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This article on granulomatous facial dermatitis presents the clinical features and its different types. Read on to know more.

Medically reviewed by

Dr. Nidhin Varghese

Published At December 21, 2022
Reviewed AtJune 26, 2023

Introduction:

Granulomatous facial dermatitis is a skin condition characterized by eruptions on the face. It generally occurs in Afro-Caribbean children at pre-pubertal age. It is usually resolved by itself without the need for treatment. They appear as yellow-brown patches. It is considered to be different from perioral dermatitis.

What Are the Clinical Features of Granulomatous Facial Dermatitis?

  • The patches are limited to areas around the mouth, nose, and eyes.

  • The condition is self-limiting.

  • There is usually no systemic involvement.

  • The lesions are asymptomatic.

  • The papules are dome-shaped.

  • It is yellow-brown or red in color.

  • Location at perioral, periocular or perinasal.

Granulomatous periorificial dermatitis is considered to be different from perioral dermatitis. Perioral dermatitis has red papules, pustules, vesicles, and redness around the mouth, nose, and eyes. However, in granulomatous periorificial dermatitis, pustules (pus-filled blisters) are absent. The lesions are yellow-brown patches. Redness and scaling are less prominent. The lesions can also be differentiated based on biopsy.

How Is Granulomatous Dermatitis Classified?

Granulomatous dermatitis can be classified into three depending on its histological appearance. Such as:

  • Palisading neutrophilic granulomatous dermatitis.

  • Interstitial granulomatous dermatitis.

  • Interstitial granulomatous drug reaction.

1. Interstitial Granulomatous Dermatitis:

A skin disorder where a particular pattern of granulomatous inflammation is seen is known as interstitial granulomatous dermatitis. The characteristic sign is called the ‘rope sign’; that is, the linear red cords that can be palpated on the lateral side of the trunk of the body.

The clinical features of interstitial granulomatous dermatitis are,

  • The clinical signs of this condition are variable.

  • Shape: round, cord-like, or annular.

  • Color: red or skin color.

  • Appearance: Papules and plaques, that is, tiny bumps or patches.

  • The lesions appear and disappear over days to months, and the shapes vary.

  • They are usually asymptomatic but, in some cases, may itch or produce a burning sensation.

  • They are generally found on the trunk but may also appear on the side of the limbs.

  • Gender: usually affects women who are middle-aged.

  • The affected individuals usually have associated autoimmune diseases.

The diagnosis of interstitial granulomatous dermatitis is,

  • The diagnosis of this variant is based on skin biopsy.

2. Palisading Neutrophilic Granulomatous Dermatitis:

Palisading neutrophilic granulomatous dermatitis was first seen arising in rheumatoid arthritis patients on their elbows called Winkelmann granuloma. Different rashes may have the same pathological appearance. Lesions may ulcerate and are often tender.

Therefore they are diagnosed based on skin biopsy. The histological appearance includes:

  • Histiocytic infiltration.

  • Degeneration of collagen.

  • Intense neutrophilic infiltration.

  • Leukocytoclastic vasculitis.

  • Based on the stage of the eruption, the histological appearance varies.

  • Palisading granulomas are also described as miniature ‘Churg-Strauss granulomas.’ Here the eosinophils envelop the degenerated collagen resembling a flame. Therefore they are also called flame figures.

3. Interstitial Granulomatous Drug Reaction:

Interstitial granulomatous dermatitis that is triggered by the use of mediation is known as an interstitial drug reaction. It is considered a separate entity.

The features of interstitial granulomatous drug reaction are,

  • Annular plaques (patches) are seen on the trunk, thighs, skin folds, and arms.

  • The skin lesion resolves when the drug is withdrawn.

Like the other two histological variants, diagnosis is based on skin biopsy. The histopathological features include:

  • Lichenoid changes.

  • Vacuolation of basal epidermal cells.

  • Neutrophil absence.

  • Collagen necrosis and floating sign.

Medications Known to Cause Interstitial Granulomatous Drug Reaction:

  • Beta-blockers.

  • TNF-alpha inhibitors.

  • Angiotensin-converting enzyme inhibitors.

  • Calcium channel blockers.

  • Statins.

  • Lipid-lowering agents.

  • Frusemide.

  • Anticonvulsants.

  • Antidepressants.

How to Differentiate Interstitial Granulomatous Dermatitis From Granuloma Annulare?

Clinically and through pathological comparison, both these diseases seem similar. Granuloma annulare also appears as bumps and patches (papules and plaques), but their location varies from that of interstitial granulomatous dermatitis. For example, granuloma annulare appears on the hands or feet on the back side, whereas interstitial granulomatous dermatitis appears on the trunk. Another difference is that granuloma annulare is associated with autoimmune diseases.

What Diseases are Associated with Granulomatous Dermatitis?

Certain conditions have been known to arise in association with granulomatous dermatitis, especially interstitial granulomatous dermatitis. However, it is less common or less known about palisading neutrophilic granulomatous dermatitis.

Autoimmune Disorders:

Granulomatous dermatitis has been seen in people with autoimmune disorders. This suggests that an immune response may be associated with the origin of the condition. The autoimmune disorders known to be associated with this condition are:

  • Systemic lupus erythematosus (the body’s immune system attacks its own cells).

  • Arthritis: Both rheumatic and non-rheumatoid arthritis. In patients with arthritis, fingers, elbows, wrists, and shoulders are involved. The joints become inflamed and painful (arthralgia). Joint involvement can happen before, after, or during the skin condition.

  • Chrug-Strauss syndrome (blood vessels’ inflammation).

  • Thyroiditis (inflammation of the thyroid gland).

  • Vitiligo (loss of skin color in patches).

Malignancy:

In some cases, interstitial granulomatous dermatitis is seen as associated with malignancy. It has been reported that the lesions cleared after lung cancer was treated. It has also been associated with lymphoma, leukemia, breast cancer, neoplasm of the endometrium, and hypopharyngeal squamous cell carcinoma.

How to Treat Granulomatous Dermatitis?

The skin lesions generally have a period of flare-ups and remission. Treatments include:

  • In cases associated with rheumatoid arthritis, Etanercept has been used and has shown complete clearance of skin lesions and improvement in arthritis.

  • In cases associated with SLE, systemic steroids have been beneficial.

The cessation of all topical corticosteroids should be the first step in therapeutic management. Granulomatous facial dermatitis may respond well to Tetracycline, Metronidazole, and Erythromycin treatment. Most importantly, it is important to reassure parents and patients that the disease is a benign, self-limiting condition.

Conclusion:

Granulomatous facial dermatitis is a skin condition that affects children of pre-pubertal age. The skin lesions affect areas around the face, nose, and eyes. The lesions are self-limiting and resolve without treatment. There are other extra-facial variations or forms of the disease, which are sometimes associated with systemic disorders.

Frequently Asked Questions

1.

What Are Granuloma Faciale (GF) Disorders?

Granulomatous skin lesions are rare, non-cancerous (benign) tumors, inflammatory skin conditions with well-defined boundaries showing follicular accentuation with dilated small blood vessels on the skin. These lesions occur due to hypersensitive reactions evoked by poorly soluble reactive substances. There are six types of granulomatous skin lesions such as tuberculoid, sarcoid, necrobiotic, suppurative, foreign body, and histoid type granuloma.

2.

What Is the Treatment for Granulomatous Allergies on the Face?

The most common treatment for the granulomatous disease of the face includes corticosteroids, and the type of steroid prescribed depends upon the severity of the condition, such as 
- Topical steroids can be applied to the skin.
- Systemic steroids such as Prednisone.
- Cortisone injections are directly administered to the affected area.
In addition to that, antibiotics can also be prescribed to fight other infections.

3.

Is Granulomatous Disorder Serious?

Usually, granulomas are benign (non-cancerous) lesions. This condition may be severe if proper treatment is not done to control the condition. Without any treatment for this condition, the patient may be more susceptible to life-threatening bacterial and fungal infections. This can involve multiple body locations and can be commonly found in people with skin lymphomas.

4.

What Are the Different Types of Granulomatous Dermatitis?

Granulomatous dermatitis usually has three different types based on its histologic appearance. 
- Interstitial Granulomatous Dermatitis - In this type of skin disorder, a specific pattern of a characteristic sign is called a rope sign that can be palpated on the lateral side of the trunk.
- Palisading Neutrophilic Granulomatous Dermatitis - Is mainly seen in patients with rheumatoid arthritis; different rashes may be seen on the body and may ulcerate and are often tender.
- Interstitial Granulomatous Drug Reaction - The granuloma type triggered by a drug reaction.

5.

Is Granulomatous Disease an Autoimmune Disorder?

Granulomatous usually do not consider an autoimmune condition. However, the two types of granulomatous disorders, such as interstitial granulomatous dermatitis (IGD) and palisaded neutrophilic granulomatous (PNGD), are rare disorders that may be associated with systemic autoimmune conditions.

6.

Who Treat Granulomas?

Granulomas are long-lasting skin lesions that usually affect children and young adults. It can cause symptoms like discolored rash or lumps under the skin. Therefore a dermatologist is the right choice to get this condition diagnosed, followed by its treatment which usually includes medications and steroid therapy.

7.

How Long Can You Live With Chronic Granulomatous Disease?

The granulomatous disease, called chronic granulomatous disease (CGD), can become chronic. This was initially termed fatal granulomatous disease of childhood as the patients may not survive past their first decade of life. The average patient survival rate is found to be 40 years.

8.

What Type of Infection Is a Granuloma?

Granulomas usually occur when immune cells gather around and may create nodules at the site of infection. The infection may occur due to bacterial, viral, or fungal infection. Moreover, the patient may become susceptible to other fungal or viral infections. One of the common complications of this is fungal pneumonia after exposure to hay or dead leaves.

9.

How to Treat Granuloma at Home?

Patients must follow the proper treatment the healthcare professional advises to treat this condition. Patients can follow some of the following steps to improve their skin health which include -
- Using a humidifier.
- Use a mild soap for the bath.
- Use lukewarm water for bathing.
- Apply moisturizing cream or ointment immediately after drying the skin.
- Avoid wearing uncomfortable or itching clothes like wool.

10.

How Long Can Granuloma Last

In the majority of cases, granulomas may disappear without leaving any trace. However, in some instances where the damage has spread to surrounding tissues, it may lead to permanent scaring or fibrosis. The treatment may take up to a few months to years, depending upon the severity, and in the majority of cases, within two years, the patient may have clear skin.

11.

Is TB a Granulomatous Disease?

Tuberculosis is caused due to a bacterial infection, and granuloma can be seen in tuberculosis. This mainly consists of the accumulation of macrophages at the site of infection, such as multinucleated giant cells, epithelioid cells, and foamy cells. The rim of lymphocytes surrounds all these cells.

12.

What Are the Causes of Granulomatous Skin Disease?

Granulomas occur when the immune cells get clumped together at the site of infection and may create tiny nodules. It may occur due to infection from bacteria, viruses, or fungi. They can be felt as lumps or swelling under the skin and may not be ulcerated. It may also occur due to other conditions such as sarcoidosis, rheumatoid arthritis, Crohn’s disease, and inflammatory bowel disease.
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Dr. Nidhin Varghese
Dr. Nidhin Varghese

Dermatology

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