Lupus miliaris disseminatus faciei--the DNA of Mycobacterium tuberculosis is not detectable in active lesions by polymerase chain reaction

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.

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.

Lupus Miliaris Disseminatus Faciei of the Posterior Eyelids: A Case Report

A 70-year-old woman with a history of Demodex blepharitis presented with a 1-year history of red-yellow nodules in the tarsus of her eyelids. Excisional biopsy revealed robust caseating granulomatous inflammation, consistent with the diagnosis of lupus miliaris disseminatus faciei. Lupus miliaris disseminatus faciei is a rare granulomatous dermatosis of unknown etiology. Estimated 200 cases have been reported to date, but none have been reported affecting the posterior lamellae of the eyelids. Lupus miliaris disseminatus faciei classically presents as symmetric yellow or brown papules on the central face and eyelid skin. Infectious etiologies and systemic granulomatous disease need to be ruled out with histologic staining and serologies.

Case for diagnosis. Eyelid edema and erythematous papules disseminated on the face

Lupus miliaris disseminatus faciei or acne agminata is a chronic inflammatory disorder of the skin, considered an intriguing entity due to its pathogenesis, which is still largely speculative. It has been linked to tuberculosis, sarcoidosis, rosacea, and other granulomatous diseases, but it is considered an independent entity.

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.

Lupus miliaris disseminatus faciei in a young male

We report a case of a healthy 26-year-old male with multiple asymptomatic reddish papules and papule-nodules on the central area of the face, persisting from more than 2 months and gradually increasing in number. An incisional skin biopsy revealed a confluent dense granulomatous infiltrate centred by large areas of eosinophilic necrosis consistent with the diagnosis of lupus miliaris disseminatus faciei (LMDF). This is a rare dermatosis first described in 1878 by Fox, that often poses a clinical challenge as it is a disease process which is difficult to diagnose. In fact, in our case, a diagnosis of LMDF was made on skin biopsy. We think that collaboration among dermatologists and General Practitioners is very important for diagnosis of rare dermatosis and especially for management of it, in order to prevent the development of depressed scars.

Acne agminata limited to the eyelids

A 45-year-old woman had a 1-year history of multiple small papules on both upper eyelids that waxed and waned in size and disappeared in the vicinity of a steroid injection site. Acne agminata (lupus miliaris disseminatus faciei, acnitis, papular tuberculid) is a rare form of necrotizing granulomatous inflammation of the dermis that has received scant attention in the ophthalmologic literature. The diagnosis is reached by excluding other forms of necrotizing granulomatous dermatitis based on clinical and histologic features.

Axillary acne agminata (lupus miliaris disseminatus faciei with axillary involvement)

Acne agminata (AA) and lupus miliaris disseminatus faciei (LMDF) have been used to describe very similar clinical conditions and it is now generally accepted that they are synonymous. The cause of these disorders has not been determined. Clinically the disease presents with often agminated redbrown to yellow papules which occasionally become pustular. Microscopically, superficial granulomatous inflammation with perifollicular caseating granulomas is the hallmark. Axillary involvement with LMDF has rarely been reported; in this area AA has been the preferred term. When only the axillae are affected, it may be difficult to distinguish acne agminata from other granulomatous diseases, especially from granulomas caused by antiperspirants containing aluminumzirconium complexes. We describe a 36-year-old woman with axillary acne agminata.

[Lupus miliaris disseminatus faciei]

Lupus miliaris faciei is a chronic inflammatory dermatosis that most often affects young adults. For years, it has successively been considered a form of tuberculosis, sarcoidosis and rosacea. Recently, some authors have proposed that it should be considered a distinct entity. It is an eruption of small, brownish-erythematous papules, primarily located on the face, especially in the periocular area. It is self-limited and generally leaves residual punctate scars. We present the case of a 25-year-old male affected by Lupus miliaris disseminatus faciei and discuss its main characteristics, as well as the different problems in its etiopathogenic classification.

Childhood granulomatous periorificial dermatitis: lupus miliaris disseminatus faciei in children?

BACKGROUND

Childhood granulomatous periorificial dermatitis (CGPD) is a granulomatous disease characterized by monomorphous, small papular eruptions around the mouse, nose and eyes, and is thought to be closely related to perioral dermatitis. This condition has always been believed to occur more commonly in dark-skinned patients; however, recent observations have revealed CGPD to occur also in white patients.

OBSERVATION

We report an 11-year-old Japanese boy with the characteristic features of CGPD. Although sarcoidosis and acne/granulomatous rosacea could be differentiated from CGPD, we could find no essential differences between CGPD and lupus miliaris disseminatus faciei (LMDF). The cases of LMDF in children, which were recorded in the Japanese literature, had highly similar clinicopathological features to those of CGPD. This case responded dramatically to topical tacrolimus in combination with the oral administration of minocycline.

CONCLUSIONS

The entity 'facial idiopathic granulomas with regressive evolution' is considered to include LMDF (a common adult form), CGPD (a rare childhood form) and perioral dermatitis (a peculiar form exacerbated by topical corticosteroids). Topical tacrolimus may be recommended as one of the therapies for LMDF as well as CGPD.

Lupus miliaris disseminatus faciei. Part I: Significance of histopathologic undertones in diagnosis

BACKGROUND

Since its clinical discovery, lupus miliaris disseminatus faciei has sporadically been reported to have different modes of clinicopathologic expression.

OBJECTIVE

The purpose of this study was to work up a list of histopathologic undertones and to project and propagate lupus miliaris disseminatus faciei as an exclusive entity. An upcoming Part II of this study will present an overview of the disease.

METHODS

All patients visiting the outpatient clinic conforming to hitherto accepted clinical features were included to study patients' age and sex, duration of the disease, and above all, conduct a detailed histopathology review. Using the detailed information obtained, an endeavor was made to organize the disease into early, fully developed, and late lesions.

RESULTS

The details of the various parameters were of great help in evolving this modus operandi. The clinical as well as histopathologic features of lupus miliaris disseminatus faciei are fairly distinct and facilitate visualizing the entity as a spectrum comprising early, fully developed, and late lesions. Further studies are called for.

Lupus miliaire disséminé de la face : 6 cas

BACKGROUND

Lupus miliaris disseminatus faciei is recognized by all authors as a unique entity, despite many appellations for this disease. In fact, the real origin and the treatment of this affection are unknown. In this study we try to specify the major histological and clinical points of diagnosis, the evolution in the mid-term and the different possibilities of the treatment.

PATIENTS AND METHODS

This is a retrospective study of the patients diagnosed with lupus miliaris and followed-up by one of us (P.M.) between 1990 and 2000.

RESULTS

There were 6 patients in this study, 5 males and 1 female. The mean age was 37 years old at the time of diagnosis. The patients exhibited a facial eruption, notably in the middle of the face, eyelids and peri-oral area. All the patients had a polymorph eruption of inflammatory and smooth papules. Many of these papules progressed in several weeks to round scars with a perpendicular carved shape. Histologically and depending of the stage of evolution of the lesion, there were some epithelioid cell and giant cell granulomas organized around the necrosis. All of the trial treatments led to failure or semi-failure. Four of the patients followed-up for several years spontaneously recovered from this disease within 2 to 4 years.

DISCUSSION

Based on the anatomical and clinical similarities observed in these 6 patients, our study confirms the authenticity of the "lupus miliaris". It did not correspond to a particular form of acne, rosacea, tuberculosis or sarcoidosis. The scars are pathognomonical of this type of eruption. No treatment seems to be efficient. However our study seems to confirm the general idea of spontaneous recovery with 2 to 4 years.