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CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 143-146

Granulomatous periorificial dermatitis in an adult: A rare case report


Department of DVL, Gandhi Hospital, Hyderabad, Telangana, India

Date of Web Publication6-Jun-2018

Correspondence Address:
Dr. Sudharani Chintagunta
Department of DVL, Gandhi Hospital, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.233845

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  Abstract 


Granulomatous periorificial dermatitis (GPD) is a distinctive form of perioral dermatitis. It is a condition of unknown etiology, characterized by monomorphic, small, papular eruptions around the mouth, nose, and eyes, and granulomatous pattern on histopathology. It is common in prepubertal children of both sexes and persists for several months. It is rarely reported in adults. We report a case of 34-year-old female who presented with erythematous to pigmented plaques with scaling involving the perioral, paranasal region, and forehead. Histopathological examination demonstrated upper dermal and perifollicular granulomatous infiltrate. Patient was treated with topical pimecrolimus and oral doxycycline.

Keywords: Adult, perioral dermatitis, pimecrolimus


How to cite this article:
Chintagunta S, Manchala S, Arakkal G. Granulomatous periorificial dermatitis in an adult: A rare case report. J NTR Univ Health Sci 2018;7:143-6

How to cite this URL:
Chintagunta S, Manchala S, Arakkal G. Granulomatous periorificial dermatitis in an adult: A rare case report. J NTR Univ Health Sci [serial online] 2018 [cited 2019 Dec 9];7:143-6. Available from: http://www.jdrntruhs.org/text.asp?2018/7/2/143/233845




  Introduction Top


Granulomatous perioral dermatitis (GPD) is a benign and self-limiting eruption of the face. It is also described as Gianotti-type perioral dermatitis, sarcoid-like granulomatous dermatitis, facial Afro-Caribbean childhood eruption (FACE), and childhood granulomatous perioral dermatitis. It is common in prepubertal children and rarely seen in adults. GPD clinically presents as asymptomatic, discrete, and erythematous to yellow-brown papules in the perioral, perinasal, or periorbital areas.[1] The eruption is asymptomatic or associated with pruritus or burning sensation. Here, we report a case of GPD in a 34-year-old female who presented with erythematous to pigmented plaques involving the perioral, paranasal, and forehead region.


  Case Report Top


A 34-year-old female presented with erythematous lesions around the mouth and forehead of 8-month duration. Initially started as asymptomatic erythema progressing to papules and diffuse plaques with scaling and hyperpigmentation in the perioral region followed by similar lesions in the paranasal and glabellar region. No h/o of similar lesions were present elsewhere on the body. There was no history suggestive of acne, atopy, or contact allergies. There was h/o of application of cosmetics and moisturizers over the lesions, which worsened the condition.

Cutaneous examination revealed well-defined erythematous to pigmented plaques associated with scaling involving the perioral, paranasal, and glabella [Figure 1] and [Figure 2], extending toward the right side of the forehead. Vermillion border of the lips are spared. Few discrete erythematous papules were present at the periphery of the perioral plaque. Based on the morphology and chronic duration, differential diagnoses of perioral dermatitis, granulomatous rosacea, acne agminata, granulomatous contact dermatitis, and reactive granulomatous dermatitis were considered. Laboratory evaluation showed no abnormalities. Skin biopsy showed granulomatous inflammation in the dermis composed of lymphocytes, histiocytes, epitheliod cells, and multinucleated giant cells [Figure 3], [Figure 4], [Figure 5]. A diagnosis of granulomatous perioral dermatitis was made based on the clinical and histopathological findings. Patient was started on doxycycline 100 mg daily for 3 months and topical pimecrolimus 1% cream twice times daily. The lesions started improving after 8 weeks and doxycycline was stopped after 12 weeks. She is under follow up with continuation of pimecrolimus for the past 4 months showing good response.
Figure 1: Perioral and paranasal region showing erythema, pigmentation, and scaling

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Figure 2: Globella and right forehead region showing erythematous plaques

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Figure 3: Scanner view (4×) of section of the skin with epidermis and dermis. Dermis shows chronic inflammatory cell aggregates in the superficial zone as well as periadnexal areas

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Figure 4: Low power (10×) of H and E stained section showing epidermis along with subepidermal aggregates of chronic inflammatory cell infiltrate comprised of lymphocytes and histiocytes

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Figure 5: High power view (40×) of granuloma in the subepidermal region comprising histiocytes, epithelioid cells, and Langhans type of giant cells

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  Discussion Top


Perioral dermatitis (POD) is a chronic papulopustular and eczematous eruption affecting the perioral and paranasal areas. It is common in young women and children. The lesions are usually confined to the chin and nasolabial folds and spares the vermilion border. The various factors implicated in the etiology are topical steroids, cosmetics, moisturizers, fluorinated toothpastes, and allergic or irritant contact agents.[1],[5] Periorificial dermatitis is the same disorder which spreads to sites other than perioral, which include perinasal, periocular, genital, and perianal regions.

GPD is considered to be an uncommon variant of POD which represent nonspecific inflammatory response to a variety of topical or systemic agents.[1],[5] It usually affects prepubertal children and is more common in dark-skinned patients.[1] This condition is characterized by monomorphous, discrete skin-colored to yellowish-brown firm papular or micronodular eruptions and diffuse erythema involving the perioral, periocular, and perinasal areas.[1] Extrafacial lesions had been reported affecting the trunk, extremities, labia majora, and occasionally generalized.[2] Histological findings of GPD reveal upper dermal and perifollicular granulomas. The prognosis is good and mild lesions may resolve spontaneously after few months. It can be differentiated from other facial granulomatous conditions by morphology and skin biopsy.

GPD can be differentiated from POD by the presence of monomorphic yellow-brown papules, lack of pustules, and a perifollicular granulomatous infiltrate on biopsy.[5] POD shows mild, nonspecific inflammation with perifollicular or perivascular lymphohistiocytic infiltration and occasional papillary edema. Granulomatous rosacea and GPD both present as red or yellow-brown, papules with a perifollicular lymphohistiocytic or granulomatous infiltrate on histopatology. GPD is differentiated from the granulomatous rosacea by an absence of erythema, telangiectasia, pustules, and edema. Lupus miliaris disseminatus faciei is chronic papular eruption with a predilection for the eyelids. The lesions are usually red or yellow-brown papules and resolve spontaneously in 12–24 months with atrophic scarring. Histopathological examination demonstrates well-formed granulomas with central caseation necrosis. Granulomatous contact dermatitis presents as eczematous lesions following contact with metals such as nickel, palladium, platinum, and gold. Reactive granulomatous dermatitis is characterized by symmetric erythematous papules on the elbows and neutrophilic inflammation with vasculitis and palisading granulomas with altered collagen.

Treatment of GPD includes oral antibiotics such as macrolides, doxycycline, tetracycline, and minocycline, and topical therapy with metronidazole, tetracycline, clindamycin, erythromycin, tacrolimus, or pimecrolimus.[1],[2],[4],[5] Oral isotretinoin may be helpful in unresponsive cases.

A thorough literature search revealed very few case reports of GPD in adults so for.[6],[7],[8] Our patient presented with diffuse pigmented scaly plaques may be due to inadvertent use of topical agents unlike the classic monomorphic yellow brown papules and showed very good response to doxycycline and topical pimecrolimus. Topical corticosteroids may initiate or exacerbate the granulomatous reaction. Hence, a high index suspicion is necessary to diagnose GPD and differentiate it from other facial granulomatous conditions for a good prognostic outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Frieden IJ, Prose NS, Fletcher V. Granulomatous perioral dermatitis in children. Arch Dermatol 1989;125:369-73.  Back to cited text no. 1
    
2.
Urbarsch AJ, Frieden IJ, Williams ML. Extrafacial and generalized granulomatous periorificial dermatitis. Arch Dermatol 2008;138:1354-8.  Back to cited text no. 2
    
3.
Gutte R, Holmukhe S, Garg G, Kharkar V, Khopkar U. Childhood granulomatous periorificial dermatitis in children with extra-facial involvement. Indian J Dermatol Venereol Leprol 2011;77:703.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Hafeez ZH. Perioral dermatitis: An update. Int J Dermatol 2003;42:514-7.  Back to cited text no. 4
[PUBMED]    
5.
Rodríguez-Martín M, Sáez-Rodríguez M, Carnerero-Rodríguez A, Rodríguez-García F, Cabrera de Paz R, Sidro-Sarto M, et al. Treatment of perioral dermatitis with topical pimecrolimus. J Am Acad Dermatol 2007;56:529-30.  Back to cited text no. 5
    
6.
Yu-Wen Li, Ming-Tuo Chuan, Shu-Ling Hu. Granulomatous Periorificial Dermatitis in a Young Woman. Dermatol Sinica 2006;24:38-41.  Back to cited text no. 6
    
7.
Loai S, Huang C. Childhood Granulomatous Perioral Dermatitis with Good Responses to Minocycline and Topical Tacrolimus, Extraordinary Significance. Austin J Dermatolog 2015;2:1034.  Back to cited text no. 7
    
8.
Vincenzi C, Parente G, Tosti A. Perioral granulomatous dermatitis: Two cases treated with clarithromycin. J Dermatol Treatment 2000;11:57-61.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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