Solid facial edema as a complication of acne vulgaris: treatment with isotretinoin

Morbihan Syndrome, a UK Case Series

PURPOSE

To describe 10 patients with Morbihan syndrome, a rare condition characterized by the slow appearance of erythema and solid edema on the upper portion of the face, and review the literature.

METHODS

Retrospective case series and review.

RESULTS

The majority of patients were male (80%), and the mean age at presentation was 67 years (range, 48-88 years); 60% had asymmetrical disease (affecting mainly the right side). All subjects underwent a lid biopsy to support the diagnosis of Morbihan syndrome, which showed features of inflammation and vascular dysfunction, highly suggestive of a rosacea histological picture complicated by chronic lymphoedema. A range of medical and surgical treatment were used with variable success. The most effective ones included oral isotretinoin, intralesional triamcinolone injections, and debulking surgery.

CONCLUSIONS

Morbihan syndrome is a rare and chronic condition. It can be difficult to treat and may require a range of interventions.

A Report of Two Cases of Solid Facial Edema in Acne

Introduction

Solid facial edema (SFE) is a rare complication of acne vulgaris. To examine the clinical features of acne patients with solid facial edema, and to give an overview on the outcome of previous topical and systemic treatments in the cases so far published.

Methods

We report two cases from Switzerland, both young men with initially papulopustular acne resistant to topical retinoids.

Results

Both cases responded to oral isotretinoin, in one case combined with oral steroids. Our cases show a strikingly similar clinical appearance to the cases described by Connelly and Winkelmann in 1985 (Connelly MG, Winkelmann RK. Solid facial edema as a complication of acne vulgaris. Arch Dermatol. 1985;121(1):87), as well as to cases of Morbihan’s disease that occurs as a rare complication of rosacea.

Conclusion

Even 30 years after, the cause of the edema remains unknown. In two of the original four cases, a potential triggering factor was identified such as facial trauma or insect bites; however, our two patients did not report such occurrencies. The rare cases of solid facial edema in both acne and rosacea might hold the key to understanding the specific inflammatory pattern that creates both persisting inflammation and disturbed fluid homeostasis which can occur as a slightly different presentation in dermatomyositis, angioedema, Heerfordt’s syndrome and other conditions.

Morbihan syndrome

We report a case of severe Morbihan syndrome (chronic erythematous edema of the upper portion of the face) in a 60-year-old man. The syndrome was characterized clinically by erythematous edema involving the forehead, glabella, and both eyelids, because of which the patient was not able to open completely his eyes. Furthermore, erythema and telangiectasiae were visible on the nose and cheeks. Laboratory and instrumental examinations were within normal ranges or negative. Histopathological examination showed dermal edema, perivascular and periadnexal lympho-histiocytic infiltrate, and sebaceous gland hyperplasia. Oral isotretinoin was ineffective despite the relatively long duration of the therapy (26 weeks).

Solid facial edema preceding a diagnosis of retro-orbital B-cell lymphoma

Persistent solid facial edema is a rare condition of unknown cause. Although acute facial edema has been associated with numerous disease processes such as infections, neoplasms, immune disorders, inflammation, neuropathic processes, drugs, mechanical obstructions, and trauma, solid facial edema has most often been associated with acne vulgaris. We report the first case, to our knowledge, of solid facial edema preceding a diagnosis of a subcutaneous scalp and orbital/periorbital B-cell lymphoma.