Annular elastolytic giant cell granuloma: sparing of a burn scar and successful treatment with chloroquine

Two Case Reports of Elastolytic Giant Cell Granuloma on the Palms

Elastolytic giant cell granuloma (EGCG) is a rare granulomatous reaction hypothesized to occur because of the altered antigenicity of elastic fibers, resulting in cellular immunological reactions. The hallmarks of EGCG include elastolysis, elastophagocytosis, and multinucleated giant cell infiltrations. EGCG was first described as an actinic granuloma or annular elastolytic giant cell granuloma that classically presents as centrifugally expanding annular plaques on sun-exposed areas. It was recently named EGCG due to reports of non-annular lesions in various sun-protected areas. Hand involvement has been described but is almost exclusively confined to the dorsal and lateral aspects of the hands. Herein, we report two cases of EGCG on the palms, an unusual site of presentation, that were successfully treated with topical, high-potency corticosteroids. EGCG should be included in the differential diagnosis in cases of annular skin lesions located on the marginal area of the palms.

A report of disseminated actinic granuloma: An unusually extensive presentation

In this report, a case of disseminated actinic granuloma in a 50-year-old female with type 2 diabetes mellitus is described. This case is unique due to the unusually extensive cutaneous involvement of the face, neck, trunk, and extremities at initial presentation. The lesions were in a striking photo-distribution, highlighting ultraviolet light as an important environmental trigger for this process. Interestingly, the patient refused the recommended systemic therapy with hydroxychloroquine, despite her significant burden of skin disease. This refusal stems from an unexpected reluctance on the part of the patient to take this medication due to the publicity and media coverage of side effects associated with inappropriate prescribing of this drug during the COVID-19 pandemic, presenting a new and surprising treatment barrier that clinicians may need to overcome.

A Retrospective Study of 105 Patients with Elastolytic Giant Cell Granuloma and a Proposal for a New Clinical Classification

Elastolytic giant cell granuloma, an idiopathic granulomatous dermatosis, is characterized by annular plaques on sun-exposed areas, and has been termed actinic granuloma or annular elastolytic giant cell granuloma. Many atypical clinical manifestations and lesions involving sun-protected areas have been reported. The aims of this retrospective study of 105 patients were to summarize the clinical and histological features of patients with this condition; to provide evidence for the viewpoint that elastolytic giant cell granuloma is a better term to include all clinical morphological types presenting with elastolysis, elastophagocytosis, and an infiltrate of multinucleated giant cells histologically; and to establish a new clinical classification. The varying clinical manifestations were further categorized into annular, papular, giant, mixed and generalized forms. The pathological manifestations were classified into giant cell, necrobiotic, histiocytic, sarcoidal and mixed patterns. Diabetes mellitus or impaired glucose tolerance were the most commonly identified comorbidities. Oral low-dose corticosteroid may be an effective treatment.

Can Methotrexate be a successful treatment for unresponsive generalized annular elastolytic giant cell granuloma? Case report and review of the literature

Annular elastolytic giant cell granuloma (AEGCG) is a rare granulomatous skin disorder, characterized by erythematous plaques with elevated borders and hypopigmented center, occurring mainly on sun exposed-skin. Histologically it presents with elastophagocytosis and elastolysis. There is no established first line treatment for AEGCG, especially for the generalized form. In a small number of cases, antimalarial drugs and tranilast, associated to topical or oral steroids, have been proposed to treat generalized AEGCG with partial benefits. We herein present the case of a patient with AEGCG aged 74 years, who was unresponsive to classical therapies, and then successfully treated with methotrexate.

O'Brien's Granuloma- A Case Report

Actinic granuloma is a self-limiting chronic disorder with elastolytic granulomas, mainly of the sun exposed skin and unknown pathogenesis. We report a case of a middle aged woman with multiple annular erythematous lesions. Histopathology revealed degenerated elastic fibres with histiocyte aggregates surrounded by multiple giant cells suggestive of elastolytic granulomas. She also had associated dyslipidemia and hypothyroidism. Actinic granuloma is relatively rare in the Indian population and needs to be differentiated from conditions like sarcoidosis and granuloma annulare.

Categorization of and comments on isomorphic and isotopic skin reactions

Locus minoris resistentiae (lmr) can be defined as a site of the body that offers lesser resistance than the rest of the body to the onset of disease. The well-known Köbner phenomenon is itself a clear example of lmr in dermatology. The new term locus maioris resistentiae (LMR), a site of the body that offers greater resistance than the rest of the body to the onset of disease, defines the opposite condition. Renbök phenomenon (reverse Köbner's isomorphic response) typically represents an example of LMR.

The immunocompromised district in dermatology: A unifying pathogenic view of the regional immune dysregulation

Besides the systemic immune deficiency, a sectorial default in immune control may occur in immunocompetent subjects. This regional immune defect can appear and remain confined to differently damaged skin areas, lately labeled immunocompromised districts (ICDs). An ICD is a skin area more vulnerable than the rest of the body for genetic or acquired reasons. Its vulnerability mainly consists in a local dysregulation of the immune control, which often facilitates (but sometimes hinders) the local onset of immunity-related eruptions or skin disorders. The factors responsible for localized immune dysregulation are multifarious, being represented by chronic lymphatic stasis, herpetic infections, ionizing or ultraviolet (UV) radiations, burns, all sorts of trauma (especially amputation), tattooing, intradermal vaccinations, and others of disparate nature (eg, paralytic stroke, poliomyelitis). Whatever the cause, in time an ICD may become a vulnerable site, prone to developing opportunistic infections, tumors, or dysimmune reactions (often of granulomatous type), strictly confined to the district itself; however, the opposite may also occur with systemic immune disorders or malignancies that selectively spare the district. In any case, the immunologic behavior of an ICD is different from that of the rest of the body. The pathomechanisms involved in this sectorial immune destabilization may reside in locally hampered lymph drainage that hinders the normal trafficking of immunocompetent cells (eg, chronic lymphedema, posttraumatic lymph stasis) or in a damage to sensory nerve fibers that release immunity-related peptides (eg, herpetic infections, carpal tunnel syndrome), or in both conditions (eg, amputation stump, radiation dermatitis). The ICD is a conceptual entity with no definite shape or dimension. It may take an extremely variable form and extent depending on the causative agent, ranging from a minimal area (eg, intradermal vaccination) or a small area (eg, herpes simplex infection), through a wide area (eg, radiotherapy), a bandlike segment (eg, skin mosaicism, herpes zoster infection), or an acral area (eg, carpal tunnel syndrome), up to a whole limb (eg, Stewart-Treves syndrome) or even an entire half body (eg, brain stroke). Varied newly coined terminology can be used to indicate the specific cause each time that it is responsible for a regional immune dysregulation. The advantage of the umbrella term ICD is that it encompasses all the possible causes involved in a local immune destabilization. An ICD may have a congenital or a postnatal origin, and interesting similarities between the two forms exist. An ICD may also take place in patients with a preexisting systemic immune deficiency, thus creating a more vulnerable site in an already vulnerable patient. Identifying a cutaneous ICD in a given patient is an important standpoint for both diagnostic and prevention purposes. This can be proven by the educative clinical examples that are reported here.

Annular elastolytic giant cell granuloma of conjunctiva: a case report

Annular elastolytic giant cell granuloma is a condition characterized histologically by damaged elastic fibers associated with preponderance of giant cells along with absence of necrobiosis, lipid, mucin, and pallisading granuloma. It usually occurs on sun-damaged skin and hence the previous name actinic granuloma. A similar process occurs on the conjunctiva. Over the past three decades only four cases of conjunctival actinic granuloma have been documented. All the previous patients were females with lesions in nasal or temporal bulbar conjunctiva varying 2-3 mm in size. We report a male patient aged 70 years presenting with a 14 mm × 7 mm fleshy mass on right lower bulbar conjunctiva. Clinical differential diagnoses were lymphoma, squamous cell carcinoma in situ and amyloidosis. Surgical excision followed by histopathology confirmed it to be a case of actinic granuloma. This is the first case of isolated conjunctival actinic granuloma of such a large size reported from India.

Clinical and morphological features of elastolytic granulomas

The authors discuss current data on the classification, etiology and pathogenesis, clinical picture, pathologic features and treatment options of elastolytic granulomas (EGs). The authors disclose main aspects of elastolysis and elastophagocytosis development. Three cases of diseases from the EG group - actinic granuloma and annular elastolytic giant cell granuloma -are described for the first time in the Russian literature.

Lack of Response to Isotretinoin in Annular Elastolytic Giant Cell Granuloma

Annular elastolytic giant cell granuloma is a rare disease characterized by annular configurated lesions with typical histopathologic findings. We report a case of annular elastolytic giant cell granuloma in a 50-year-old male patient. Treatment modalities for this disease are limited and mostly unsatisfactory, although isotretinoin was found to be effective in a single case. However, systemic isotretinoin treatment of 12 weeks' duration was of no benefit in the presented case.

Hybrid Clinical and Histopathological Pattern in Annular Lesions: An Overlap between Annular Elastolytic Giant Cell Granuloma and Granuloma Annulare?

Annular elastolytic giant cell granuloma (AEGCG) is a rare granulomatous skin disease of unclear pathogenesis which belongs to the group of disorders in the skin and elastic fibers with similar clinical features of granuloma annulare (GA). This case report is intended to describe a rare hybrid pattern in histopathology demonstrating coexistence of AEGCG and GA. An endocrine disease, such as diabetes mellitus (DM), could contribute to the coexistence of both lesions, and this possibility must be included in the medical investigation.

Annular Elastolytic Giant Cell Granuloma Associated with Temporal Arteritis Leading to Blindness

Background:

Annular elastolytic giant cell granuloma (AEGCG) is a rare granulomatous disorder characterized by giant cells in the dermis phagocytosing damaged elastin fragments.

Objective:

We report a case of a 71-year-old man presenting with erythematous plaques in predominantly sun-exposed areas.

Method:

A diagnosis of AEGCG was made based on the clinical and histologic picture, and treatment with systemic steroids was initiated. However, while tapering the steroid dose, the patient developed a radiating headache that progressed to temporal arteritis and eventual blindness in the right eye.

Conclusion:

There have been only two previous case reports presenting an association between AEGCG and temporal arteritis. This report explores AEGCG and its possible relationship to temporal arteritis along with possible treatment regimens cited in the current literature.

Granuloma anular elastolítico gigantocelular: relato de caso

O granuloma anular elastolítico gigantocelular é dermatose granulomatosa rara, caracterizada, histologicamente, por fagocitose das fibras elásticas por células gigantes multinucleadas e, clinicamente, por placas anulares com bordas elevadas e centro atrófico, com preferência por áreas expostas. A patogênese é controversa. Descreve-se um caso de mulher de 44 anos, com achados clínicos e histológicos clássicos, que apresentou boa resposta à hidroxicloroquina, após o período de 1 mês

[Annular elastolytic giant cell granuloma]

BACKGROUND

Annular elastolytic giant cell granuloma (AEGCG) is a rare form of granulomatous dermatosis. It is characterised histologically by phagocytosis of elastic fibres by multinucleated cells. We report a favourable outcome in a case of AEGCG following PUVA therapy and treatment with synthetic antimalarials.

PATIENTS AND METHODS

A 67-year-old retired wine grower presented with highly pruritic annular lesions with raised borders on the shoulders and trunk that had been present for several months. Histological examination of a biopsy sample from the erythematous border was characteristic of AEGCG. Various topical treatments proved ineffective and systemic corticosteroids attenuated the patient's pruritus but had no effect on the skin lesions. PUVA therapy resulted in regression of lesions on the trunk, but the rash spread to the patient's arms and was covered with epidermal microcysts. PUVA therapy was discontinued and treatment with a synthetic antimalarial (hydroxychloroquine 400mg/d) was initiated, resulting in complete regression of the lesions.

DISCUSSION

AEGC was isolated in 1979 by Hanke et al. on the basis of five cases seen in females. This is a rare form of dermatosis with some 30 cases being reported in the English literature. The clinical aspect is fairly evocative, with erythematous papular lesions, either alone or in groups, with a raised border and a lighter centre tending towards atrophy. In most cases, the lesions are found predominantly in areas exposed to sunlight. The histological appearance is characteristic, with an image of giant cell elastophagic granuloma from which the name of the disease is taken. This appearance allows the disease to be differentiated from a number of other granulomatous diseases. The aetiology is unknown and treatment is empirical. Spontaneous cure can occur and consistent results have not been obtained with any treatments. In our case, PUVA was partly successful, and the synthetic antimalarials resulted in complete regression of residual lesions.

[Annular elastolytic giant cell granuloma: a case report located in non-sun exposed areas]

Annular elastolytic giant cell granuloma (AEGCG) is an uncommon entity clinically characterized by erythematous annular plaques with atrophic and hypopigmented center, that predominates in sun-exposed zones. The histology shows a granulomatous infiltrate without palisading image, made up of lymphocytes, histiocytes and giant cells, with phagocytosis of elastic fibers, without necrobiosis or mucin deposit. We present the case of a male patient with atypical clinical manifestation on the non-sun exposed skin and AEGCG characteristic histology.

Regression of Papular Elastolytic Giant Cell Granuloma Using Narrow-Band UVB Irradiation

A 71-year-old Japanese man presented with asymptomatic, firm, brown-red papules on the dorsum of his left hand and back. A biopsy specimen revealed granulomatous infiltration consisting of multinucleated giant cells and histiocytes in the upper dermis. Elastic fibers were absent in the upper dermis, having been phagocytosed by giant cells. These papular elastolytic giant cell granuloma lesions regressed very well with narrow-band ul traviolet B irradiation, with only residual brown pigmentation left after treatment.

A reticular variant of elastolytic giant cell granuloma

An 80-year-old man presented with a distinctive reticular form of elastolytic giant cell granuloma (EGCG). This represents a rare subset of EGCG, thus belonging to a larger group of granulomatous skin diseases with poorly understood pathogenesis. The patient exhibited numerous erythematous to brownish, sharply demarcated patches of reticulate appearance with partial central atrophy and nonelevated margins, which involved the trunk and especially chest, shoulders, upper back and arms. Skin biopsy revealed a granulomatous infiltrate with multinucleate histiocytes containing remnants of elastic fibres in conjunction with a significant loss of elastic fibres throughout the dermis. There is little published information on treatment, which remains unsatisfactory.

Annular elastolytic giant cell granuloma in an infant: Improvement after treatment with oral tranilast and topical pimecrolimus

Annular elastolytic giant cell granuloma (AEGCG) is a rare granulomatous skin disease of unknown origin that is characterized clinically by annular patches with erythematous borders and hypopigmented centers and histologically by loss of elastic fibers and elastophagocytosis. We report a case of AEGCG in an 8-month-old boy that was successfully treated with oral tranilast and topical pimecrolimus (Elidel 1.0% cream).

Therapy of noninfectious granulomatous skin diseases with fumaric acid esters

BACKGROUND

Noninfectious granulomatous skin diseases are inflammatory disorders of unknown aetiology which are often recalcitrant to common anti-inflammatory treatment regimens. Recently, in several case reports, fumaric acid esters (FAE) have proved beneficial in granulomatous skin diseases, but studies on a larger collection of consecutive patients have not yet been performed.

OBJECTIVES

To investigate the therapeutic efficacy of FAE for the treatment of granulomatous skin diseases.

PATIENTS AND METHODS

The therapeutic efficacy and side-effects of FAE were analysed retrospectively in 32 patients with disseminated granuloma annulare (n = 13), annular elastolytic giant cell granuloma (n = 3), sarcoidosis (n = 11), necrobiosis lipoidica (n = 4), or granulomatous cheilitis (n = 1).

RESULTS

Three patients discontinued treatment within 4 weeks because of side-effects. Of the remaining 29 patients, 18 patients responded to treatment with FAE. Marked improvement or complete clearance was seen in seven patients. We observed a slight to moderate improvement in 11 patients, and 11 patients did not respond. In patients showing a complete remission, the maximum effect was observed after 8.5 months (SD +/-6 months, range 3-20 months). In two patients with systemic sarcoidosis, the pulmonary changes improved in parallel with the skin. Side-effects were usually mild and resolved spontaneously upon dose reduction or discontinuation of the therapy.

CONCLUSIONS

The data presented here indicate that FAE may be considered for the treatment of recalcitrant granulomatous skin disease.

Actinic granuloma successfully treated with acitretin

Actinic granuloma is a rare skin disorder that develops in an area of actinic elastosis. The pathogenesis of the disease is obscure but the most accepted hypothesis implicates the solar radiation as the triggering factor. Typically the disease presents in middle-aged individuals with significant past sun-exposure and involves mainly the sun-exposed skin. It manifests as asymptomatic annular patches with elevated borders and central atrophy and shows little tendency to regression. Several treatments have been tried with variable success. We present a 74-year-old male who consulted our department for annular atrophic plaques involving his forehead and nose, present for 8 months and insidiously spreading but otherwise asymptomatic. A biopsy confirmed the clinical suspicion of actinic granuloma and excluded other possibilities. Our patient was commenced on acitretin 25 mg/day and showed a remarkable improvement within a year; the lesions stopped spreading and almost disappeared.

The spectrum of primary cutaneous elastolytic granulomas and their distinction from granuloma annulare: a clinicopathological analysis

AIMS

Actinic granuloma (AG) and annular elastolytic giant cell granuloma (AEGCG) are terms commonly applied to cutaneous lesions characterized by elastolysis, elastophagocytosis and a multinucleated cell infiltrate. The aim of this study was to clarify the relationship of these lesions to granuloma annulare (GA) which they resemble clinically.

METHODS AND RESULTS

The clinicopathological data of 20 patients whose biopsies showed the histology of elastolytic granuloma as well as those of previously published cases with identical tissue changes were analysed to assess differences between AG, AEGCG and GA. The tissue changes of AG and AEGCG are identical and differ substantially from GA because of the predominant elastolysis and elastophagocytosis in the absence of necrobiosis and palisading granuloma. Actinic and/or thermal injury could be elicited frequently in the patient's history, but not always.

CONCLUSIONS

AG may be considered as an aetiopathological subdivision of AEGCG. Patients with biopsies showing both GA and AEGCG are occasionally encountered. AEGCG is easily differentiated from incidental elastolysis which may be seen in a variety of aetiologically unrelated processes.

Antimalarials in cutaneous lupus erythematosus: mechanisms of therapeutic benefit

Antimalarials are arguably the best modality currently available for treating patients with cutaneous lupus erythematosus (LE). Although antimalarials have been used for decades in treating cutaneous LE, the precise mechanisms by which they provide therapeutic benefit are not well defined. The putative mechanisms by which antimalarials might provide therapeutic benefit to patients with cutaneous LE include a number of interrelated anti-inflammatory and immunosuppressive effects that include photoprotection, lysosomal stabilization, suppression of antigen presentation, and inhibition of prostaglandin and cytokine synthesis. If we had a more precise understanding of how antimalarials provide therapeutic benefit in cutaneous LE we might gain better insight into the pathogenic mechanisms of LE and ways of developing better therapies for afflicted patients.

Metastatic Crohn's disease of the forehead

BACKGROUND

Metastatic Crohn's disease (CD) involves the presence of cutaneous granuloma distant from the intestinal lesions related to the disease, usually observed in colonic CD.

CASE HISTORY

A 35-year-old female with a permanent ileostomy following proctocolectomy for CD presented in 1999 with a 2-month history of an unusual skin lesion of the forehead. A diagnosis of CD of the ileum, colon, and rectum had been made in 1994. In 1997, a proctocolectomy with ileostomy was performed due to fistulizing severe refractory disease. Microscopic aspects of the intestinal lesions showed deep and fissuring ulcers. After surgery, she went into remission, and a small bowel follow-up in 1999 showed no recurrence, when she presented with the skin lesion of the forehead. MICROSCOPIC DATA: Histological analysis of endoscopical and surgical intestinal specimens showed chronic granulomatous inflammation of the ileum, colon, and rectum, confirming the diagnosis of CD. The forehead skin biopsy was examined by three independent histopathologists. The lesion was composed of numerous small granulomas (Ziehl-Nielsen negative), with no foreign bodies, mainly composed of CD68-positive and periodic acid Schiff-negative monocytes. Despite the low number of lymphocytes, the macroscopical and microscopical aspect of the forehead lesion, together with the clinical history, led to a diagnosis of rare metastatic CD of the forehead.

CONCLUSIONS

This case report describes the development of an unusual granulomatous skin lesion of the forehead in a patient with established CD showing no postoperative recurrence.