Granulomatous Rosacea Versus Lupus Miliaris Disseminatus Faciei—2 Faces of Facial Granulomatous Disorder: A Clinicohistological and Molecular Study

From drug therapy failures to laser therapy victory: A case report and literature review of lupus miliaris disseminatus faciei resolution

Key Clinical Message

Pulsed dye laser (PDL) has proven effective in resolving lupus miliaris disseminatus faciei (LMDF) where drug therapies have failed with a lack of treatment consensus for LMDF, considering early PDL intervention is crucial to achieve resolution without scarring, prevent relapse, and enhance overall treatment outcomes.

Abstract

Lupus miliaris disseminatus faciei (LMDF) is a rare inflammatory and granulomatous dermatologic disease that primarily affects the face. The optimal treatment for LMDF remains controversial, and there is a lack of consensus on the most effective therapy. This case report highlights the successful use of a 595 nm pulsed dye laser (PDL) in the treatment of LMDF following unsuccessful drug therapy. A 28-year-old male presented with reddish-brown eruptions on his face that had persisted for several months. Clinical examination revealed discrete dome-shaped eruptions in clusters on the central area of the face. Histopathological examination confirmed the diagnosis of LMDF, based on the presence of epithelioid granulomas with central caseous necrosis. Previous treatment with an oral isotretinoin and methotrexate combination also failed to yield satisfactory results. After discontinuing drug therapy, the patient underwent five sessions of PDL treatment. Ten days after the first session, the eruptions began to regress without scarring. Subsequent PDL sessions led to the complete resolution of the eruptions. The patient experienced no relapse during the follow-up period. This case report suggests that PDL treatment may be an effective option for LMDF, particularly in cases where drug therapy has failed. Early initiation of laser treatment may prevent scarring, minimize the adverse effects associated with drug therapy, and reduce the risk of disease relapse. Further research and controlled trials are needed to establish the efficacy of laser therapy in the treatment of LMDF.

Clinical analysis of lupus miliaris disseminatus faciei: a cross-sectional study and literature review

Background

The clinical similarity of lupus miliaris disseminatus faciei (LMDF) and other papular granulomatous facial disorders often makes its correct diagnosis challenging. Diagnosis often requires the assistance of pathological examination, and dermoscopy can be used as an auxiliary and non-invasive examination method, however, the current findings remain incomplete.

Objectives

This study aimed to summarize the clinical, histopathological and dermoscopic features of LMDF in the Chinese Han population and aiming to provide practical significance to correct diagnosis.

Methods

109 patients of LMDF were collected in the Department of Dermatology, the Second Affiliated Hospital of Xi'an Jiaotong University from August 2015 to August 2023. The clinical and histopathological manifestations of all patients, as well as the dermoscopic image features of 44 cases, including background, follicular findings, vessels, and other structures, were summarized and evaluated.

Results

The most significant histopathological features of LMDF in 109 cases is epithelioid granulomatous infiltrate in the superficial dermis, with or without caseation. The most significant dermoscopic features of LMDF in all 44 cases were orange structureless background (30/44), follicular plug (32/44), follicular white scar-like area (32/44), unspecific linear vessels (24/44), linear vessels with branch (24/44) and white streaks (18/44).

Conclusion

Histopathologically, LMDF is characterized by the presence of epithelioid granulomatous infiltrate in the superficial dermis, with or without caseation. Dermoscopically, it exhibits a distinctive orange structureless background, follicular plug, follicular white scar-like area, nonspecific linear vessels, linear vessels with branches, and white streaks.

Subtlety of Granulomatous Mycosis Fungoides: A Retrospective Case Series Study and Proposal of Helpful Multimodal Diagnostic Approach With Literature Review

ABSTRACT

Granulomatous mycosis fungoides (GMF) harbors a worse prognosis compared with classic MF and remains a significant diagnostic dilemma. We analyzed clinicopathologic, immunophenotypic, and molecular characteristics of GMF to develop a diagnostic algorithm. Our methodology involved a retrospective case series study of patients with GMF from our database between 2014 and 2020. A total of 8 patients with 9 biopsies of GMF were identified. Skin manifestations had variable clinical phenotype. Histologically, all cases demonstrated atypical CD4+ T-cell infiltrate with scant in 50% (n = 4), focal 37.5% (n = 3), and absent 25% (n = 2) epidermotropism. Granuloma formation was seen in 77.8% biopsies (n = 7) with sarcoid-type granulomas in 57.1% (n = 4) and granuloma annulare-like type in 42.9% (n = 3). In 66.7% of biopsies (n = 6), the CD4:CD8 ratio was >4:1 and 66.6% (n = 6) of biopsies showed ≥50% loss of CD7 expression. T-cell receptor gene rearrangement studies performed on biopsy sections were positive in all biopsies (n = 6), whereas peripheral blood T-cell receptor gene rearrangement studies did not identify clonality. In conclusion, GMF has subtle or absent epidermotropism and variable granulomatous reaction; thus, the diagnosis requires a multimodal approach, and our proposed algorithm provides a framework to approach this diagnostic challenge.

Unusual Spurts of Rosacea Like Dermatoses, Posing a Diagnostic Dilemma During Covid-19 Pandemic: A Cross-Sectional, Observational Study From a Tertiary Care Centre

Background:

The gradual opening of healthcare system since second week of May 2020 following lockdown imposed due to corona virus pandemic saw spurts of cases of unexplained central facial dermatoses in subset of previously healthy people. The aim of the study was to find out the cause and establish the definitive diagnosis of unusual occurrence of facial dermatoses on previously healthy people so that an appropriate management can be offered to the patients.

Materials and Methods:

It was a cross-sectional, observational study carried during May 15 to July 15, 2020 at a tertiary dermatology center. All cases presented with erythema on face and papular or pustular lesions on central facial area of not more than 2 months of duration were included in the study.

Results:

Total 81 patients visited skin OPD with facial dermatoses of various types during this period, out of which 21 patients fulfilled the inclusion criteria. This was 0.72% (21/2900) of total skin OPD of the 2 months. All the patients had been using face masks during this period of symptoms due to the ongoing coronavirus situation. Dermatological examination revealed only erythema on the central area of face (n = 10), erythema and few papules (n = 3), erythmatous papules and pustules (n = 5), and erythematous papules, pustules, and telengiectasia (n = 3). All the skin biopsies showed predominantly epithelioid cells, noncaseating granuloma with a variable degree of infiltrate.

Conclusion:

There has been a definite change in the lifestyle due to the current Covid-19 pandemic. People are compulsorily using face masks to avoid the spread of Covid-19 infection. This change in behavior has brought out a surge of rosacea like lesions on the covered area of face. Partly, it can be explained by change in innate immunity due to excessive sweating and change in microenvironment of skin.

Non-Infectious Granulomatous Dermatoses: A Pathologist's Perspective

Granulomatous dermatitis (GD) is one of the commonest tissue reaction patterns encountered in dermatopathology practice. Granulomatous inflammation in the skin can be seen in a wide range of conditions, thus, granulomatous dermatitis always poses significant challenge even to the astute dermatologists and dermatopathologists. Broadly, granulomatous dermatitis is divided into two groups-infectious and non-infectious, the prevalence of both highly variable and show overlapping pathology. However, there are subtle histological clues, which when combined with clinical features, help to narrow down the differential diagnosis. Thus, a good Clinicopathological correlation (CPC) along with histochemical stains, culture and ancillary techniques including molecular studies are required for arriving at a definite diagnosis. In this review, we shall discuss the histological clues to diagnose non-infectious granulomatous dermatitis (NIGD) and their differential diagnoses.

Lupus Miliaris Disseminatus Faciei versus Granulomatous Rosacea: A Case Report

Lupus miliaris disseminatus faciei (LMDF) and granulomatous rosacea are 2 distinct inflammatory dermatoses with overlapping clinical features: reddish-yellow papular eruptions localized on the central face. Consequently, LMDF can easily be misdiagnosed as granulomatous rosacea or vice versa. Because delayed treatment in LMDF may increase chances of permanent scar formation, accurate diagnosis is important. We therefore analyzed published literature and case studies to organize the essential features differentiating LMDF from granulomatous rosacea. In addition, we report each case of LMDF and granulomatous rosacea for direct comparison.

Immune profiling of lupus miliaris disseminatus faciei and successful management with anti-tumour necrosis factor therapy

Lupus miliaris disseminatus faciei (LMDF) is a chronic inflammatory dermatosis of unknown aetiology, most often seen in young adults. Although many treatments for LMDF exist, treatment guidelines have not been developed, and response to therapy is generally unpredictable. We present the results of transcriptomic analysis of LMDF lesional skin, which revealed a variety of differentially expressed genes linking LMDF to alterations in innate and adaptive T helper 1 immunity. Immunohistochemical analysis was also performed, identifying similar changes in T-cell immune responses. Given evidence for increased tumour necrosis factor (TNF) pathway activity, our patient, who had previously been refractory to multiple treatments, was initiated on TNF inhibitor therapy with excellent response. This characterization of the LMDF immune response may lead to improved treatment of this condition.

Cutaneous Manifestations of "Lupus": Systemic Lupus Erythematosus and Beyond

Lupus, Latin for "wolf," is a term used to describe many dermatologic conditions, some of which are related to underlying systemic lupus erythematosus, while others are distinct disease processes. Cutaneous lupus erythematosus includes a wide array of visible skin manifestations and can progress to systemic lupus erythematosus in some cases. Cutaneous lupus can be subdivided into three main categories: acute cutaneous lupus erythematosus, subacute cutaneous lupus erythematosus, and chronic cutaneous lupus erythematosus. Physical exam, laboratory studies, and histopathology enable differentiation of cutaneous lupus subtypes. This differentiation is paramount as the subtype of cutaneous lupus informs upon treatment, disease monitoring, and prognostication. This review outlines the different cutaneous manifestations of lupus erythematosus and provides an update on both topical and systemic treatment options for these patients. Other conditions that utilize the term "lupus" but are not cutaneous lupus erythematosus are also discussed.

Granulomas in Dermatopathology: Principal Diagnoses - Part 1

This series of 2 articles on dermatopathologic diagnoses reviews conditions in which granulomas form. Part 1 clarifies concepts, discusses the presentation of different types of granulomas and giant cells, and considers a large variety of noninfectious diseases. Some granulomatous diseases have a metabolic origin, as in necrobiosis lipoidica. Others, such as granulomatous mycosis fungoides, are related to lymphomas. Still others, such as rosacea, are so common that dermatologists see them nearly daily in clinical practice.

Granulomatous Rosacea in Korean Patients: Diagnosis Based on Combining Clinical and Histological Findings

BACKGROUND

Granulomatous rosacea (GR) is a rare inflammatory skin disease, which is considered a variant of rosacea, apart from other types of rosacea.

OBJECTIVE

This study aimed to summarize the characteristics of Korean patients diagnosed with GR by combining clinical and histological findings.

METHODS

Fifteen cases, both clinically and histologically consistent with GR, were selected and were subsequently analyzed to describe clinical and histological characteristics.

RESULTS

A total of 20 patients showed granulomatous infiltration in skin biopsies, but only 15 of them were clinically consistent with GR. Five patients who showed granulomatous inflammation were clinically consistent with erythematotelangiectatic or papulopustular rosacea. Among 15 patients, 13 (86.7%) were female and 2 (13.3%) were male. The most frequently involved area was the cheek, and none of the patients showed extrafacial lesions. There seems to be a possibility that treatment duration may be associated with the treatment response.

CONCLUSIONS

This study confirms clinical characteristics of GR based on the diagnosis combining both clinical and histological findings.

Lupus miliaris disseminatum faciei in a patient with systemic lupus erythematosus and Sjögren's syndrome

We herein report a rare case of lupus miliaris disseminatus faciei on the chin and neck in a patient with systemic lupus erythematosus and Sjögren's syndrome. Histopathological features showed focal aggregates of epithelioid granulomas accompanied by mononuclear cell infiltration in the upper dermis. Immunohistological examination showed enhanced expression of CD68 and CD163. Recent findings have implicated a key role of innate immunity in the pathogenesis of systemic lupus erythematosus, and alteration in M1 and M2 macrophage profile has been suggested. Increased expression of CD163 in the affected skin and other organs, and elevated serum levels of soluble CD163, are reported in systemic lupus erythematosus. Our results may suggest that activated M2 macrophages participated in the induction of lupus miliaris disseminatus faciei in a patient with systemic lupus erythematosus and Sjögren's syndrome.

Dermoscopic features of lupus miliaris disseminatus faciei: Distinct aspects depending on disease stage

Dermoscopy is a useful tool that helps distinguish lupus miliaris disseminatus faciei (LPDF) from sarcoidosis and tuberculosis. Follicular keratotic plugs (FKP) represent the hallmark of LPDF. Dermoscopic aspect of LPDF changes through the course of the disease.

Demodex-induced Lupus miliaris disseminatus faciei: A case report

RATIONALE

Lupus miliaris disseminatus faciei (LMDF) is an inflammatory granulomatous skin disease without a clear etiology that frequently involves the middle area of the face and the upper eyelids. Pathological features of the disease include caseation necrosis and epithelioid granuloma. Consensus treatment for LMDF is currently unavailable.

PATIENT CONCERNS

A 47-year-old Chinese female patient who presented with facial pruritic, erythematous papules 8 months before this study. She was diagnosed with skin tuberculosis at another hospital and given antituberculosis medication. However, the treatment was not efficacious.

DIAGNOSES

In this study, the diagnosis of Demodex-induced LMDF was made by a dermatologist according to physical examination, skin biopsy pathology, and microscopic examination.

INTERVENTIONS

The patient was given ornidazole tablets (500 mg twice a day) and recombinant bovine basic fibroblast growth factor gel (0.2 g/cm twice a day) for an 8-week period.

OUTCOMES

Eight weeks after the treatment, the facial erythematous papules were improved, and no new skin lesions were observed. The patient showed no signs of recurrence during the 6-month follow-up.

LESSONS SUBSECTIONS

This case showed that ornidazole combined with recombinant bovine basic fibroblast growth factor gel might be useful in treatment of Demodex-induced LMDF. In addition, the results suggested that pathological caseation necrosis was caused by a series of inflammatory and immune responses to Demodex infection.

Plasmacytoid dendritic cells in granulomatous variant of mycosis fungoides

INTRODUCTION

Granulomatous mycosis fungoides (MF) is a rare variant in which granulomas are associated with other typical signs of MF. Its prognosis is worse than that of classical MF. Plasmacytoid dendritic cells (PDCs) are a subset of interferon-producing dendritic cells that link the innate and the adaptative immune responses. They have also been related to tolerance to certain tumors such as melanoma.

MATERIALS AND METHODS

In this article, we examined for the presence of CD123+ PDC in six cases of granulomatous MF from our archives.

RESULTS

We found clusters of 10 or more positive cells in three of six cases of granulomatous MF (two women and a man, in their sixth and seventh decade). Although in two of these three cases the granulomatous response was extensive, in the other, it only represented 10% of the infiltrate of the biopsy. In all three cases, the granulomas were epithelioid, sarcoidal type.

CONCLUSIONS

CD123+ PDC can be identified in granulomatous MF. The pathogenic and prognostic role of this finding requires further clarification.