Granuloma faciale entirely in an extrafacial location

978

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impact of the sequence variation at the VDR ]ocus is attenuated under supraphysiological concentrations of vitamin D. awaits for further studies. Departments of Medicine and *Dermatology. University of Helsinki. FIN-00290 Helsinki. Finland

K.KONTIILA S.VAJJMAKI K.KAINULAINEN

A-M.VlTTANEN J.KESKI-OJA*

References 1 Hoiick MF. 1,25-Dihydruxyvitamin Dj and the skin: a unique applicaliun for the treatment of psoriasis. Proc Soc Exp Biol Med 1989: 191:246-57. 2 Lea AP. Goa KL. Calcipotriol. A review of its pharmacological properties and therapeutic efficacy in the management of psoriasis. Gill Imimmother 1996; 5: 230-48. 3 Morrison NA. Qi JC. Tokita A et al. Prediction of bone density from vitamin D receptor alleles. Nature 1994; 567: 284-7. 4 Hustmyer FC Peacock, Hui S et ai. Bone mineral density in relation to polymorphism at the vitamin D receptor gene locus. / Clin Invest 1994; 94: 2130-4. 5 Dawson-Huj^hes B. Harris SS. Finneran S. Calcium absorption on high and low calcium intakes in relation to vilamin D receptor genotype. / C7(H I'.ndocrinol Metah 1995; 80: 3657-61. 6 Morrison NA. Yeoman R, Ktlly PI. Eisman (A. Contribution of transacting factor alieles to normal physiological variability; vitamin D receptor gene polymorphisms and circulating osteocalcin. Prac Nat! AcadSci VSA 1992: 89: 6665-9. 7 Viitanen A-M. Karkkainen M. l,aitinen K et a!. Common polymorphism of the vitamin D receptor gene is associated with variation of peak bone mass in young Finns. CalcifTissuf Inl 1996; 59:231-4.

Figure 1. Brownish plaques are present on the upper back.

Granuloma faciale entirely in an extrafacial location SIR. Granuloma faciale Is a distinct entity diagnosed on a combination of clinical and histopathological findings. Clinically, it occurs as brownish macules, plaques or nodules nearly always limited to the face. We report a 51-year-old woman with granuloma faciale located on the back. A 51 -year-old woman was seen with a 6-month history of persistent, asymptomatic plaques on her trunk. She had three brownish, well-demarcated, smooth, slightly indurated, oval plaques, 1 - i cm in diameter, on the upper part of her back (Fig. 1). Full blood count, liver function tests, creatinine. and urinalysis were normal. A skin biopsy showed a dense polymorphous infiltrate, mainly located in the middle and lower dermis. and separated from the epidermis by a narrow Grenz zone (Fig. 2|. The infiltrate consisted of lymphocytes, histiocytes, neutrophils and eosinophils. Fibrinoid degeneration in the vessel walls and nuclear dust around the capillaries were present. The patient was treated with dapsone. SOmg daily for H months, without improvement. Granuloma faciale is an uncommon dermatosis characterized clinically by asymptomatic, brownish-red, slowly enlarging patches, and microscopically by a dense polymorphous dermal cellular infiltrate, consisting of lymphocytes, plasma cells, eosinophils, neutrophils and histiocytes. In small lesions.

Figure 2. A mixed infiltrate composed of eosinophils. neutrophils. lymphocytes and histiocytes. separated from a normal epidermis hy a Grenz zone (haematoxylin and eosin.xlOO].

this cellular infiltrate is limited to perivascular sites, whereas in larger lesions it is more dilluse. A true vasculitis may be present. A characteristic subepidermal Grenz zone is present. The lesions nearly always involve the face, although at least eight patients with extrafacial lesions have been reported (Table 1).'"' All these patients had typical facial lesions and

1997 British Association of Dermatologists. Britis/i }ourmil oj Dermatoloifn. 136. 968-y81

CORRESPONDENCE

Table 1. Reported cases of extrafacial involvement in granuloma faciale

Authors

Sex

Age Facial lesions

Extrafacial locations

Konohana Lever et a!.' Okun et al.'* Pedace & Perry'

M M M M F M F M F

59 53 54 45 47 44 50 57 51

Yes

Back Back Left band Left arm Chest, arms Back, shotjlders, cbest Back Thighs

No

Back

Rusin et al.' Sears et al.'

Present case

Yes Yes

Yes Yes Yes Yes Yes

subsequently developed histologicaily contitmed plaques and ntxlules on extratacial sites, The extrafacial lesions started 1-^9 years after the appearance of the facial eruption. No previously reported cases had lesions only in an extrafacial location. Granuloma laciale (GF) must be differentiated from erythema elevatum diutinum (EED). EED usually presents symmetrically on the back of the hands and the extensor surface of the knees and elbows, around the wrists and ankles or on the buttcx"ks. in distinction to the asymmetrical facial, truncal and proximal distribution of extrafacial granuloma faciale/ Histologicaily, REI) differs from gnuiuloma faciale hy showing fewer eosinophils. more dense vascular involvement and less regular sparing of the overlying epidermis.'' EHJ usually responds well to dapsone, but granulotna faciale does not." The lesions in our patient were not located in acral areas and did not respotid to dapsone. Biopsy showed a prominent eosinopliilic infiltrate and a Grenz zone. Thus, otir patient was considered to have granuloma faciale in an extrafacial location. She is possibly the first reported case. Departments of Dermatology and *Pathology. Hospital 12 lie Octubre. Madrid, Spain

E.CASTANO A.SEtlHRAtX) L.IG1£SIAS F.LopRZ-Rios* Z - P E R ALTO-

References 1 Perrin C. Lacour }P, Micbiels JF (•( iiI. Cranulome facial. Ann Dermatol Venercol 1992: 119: 509-16. 2 Kunohana A. Extrafacial granuloma faciale. / Dermatol 1994: 21: 680-2. i I.«ver WF, Lane CG. Dovi'ning ]G. Spangler AS. Eosinopbilie granuloma of the skin. Report of three eases. Arch Dermatol Syphilol 1948; 5 8 : 4 3 0 - 8 . 4 Okun MR, Bauman L Minor D. Cranuloma faeiale with lesions on tbe face and hand. Arch Deritmtol 1965: 92: 78-80. 5 Pedace F|. Perry HO, Granuloma faciale. A elinieal and histopathologic review. Arch Dermatol 1966: 94: J87-95. 6 Rusin LJ. Dubin HV, Taylor WB. Disseminated granuloma faciale. Arch Dermatol 1976: 112: 1575-7. 7 Sears JK, (Jitter DG. Stone MS. Extrafacial granuloma faciale. Arch Denmtol 1991: 127: 742-3. 8 Ryan T|. Cutaneous vasculitis. In: Textbook of Dermatolofin

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(Champion RH, Burton |L. Ebllng FJG, eds|, 5th edn. Vol. i. Oxford: Blackwell Sdentilic Piihlicatiuns, 1992: 1929-31. 9 Katz SI. Erythema elevatum diulinum. In: Denimtology in General Me(«cinf (Fitzpatrick TO, Eisen AZ, Wolff K cl a!, eds), 4tb edn. Vol. 1, McGraw-Hill, 1993: 1167-71.

Uveitis in psoriasis associated with HLA-B51; a link to Beh^et's disease? SiR, Uveitis or iridocyclitis is a rare complication of psoriasis,' and it has been suggested that uveitis is associated with the presence of HLA-B2 7 in such patients." We describe a patient with uveitis associated with psoriasis vulgaris in whom HLA typing revealed that the patient was homozygous for HLA-B51. A 5()-year-old Japanese woman developed scaly erythematous plaques on her trunk, that gradually spread over her extremities and head. She also had blurred vision. Two years later, she experienced an exacerbation of the blurred vision associated with a high fever, arthralgia, and an exacerbation of her eruption. An ophthalmologist diagnosed uveitis. Examination of her skin showed multiple scaly erythematous plaques on her trunk, extremities and head. No remarkable pustules were seen on the plaques. No urethritis or aphthae were observed. Histological examination of a scaly plaque on her back showed an acanthosis. hyperkeratosis, dyskeratosis and part of a spongiform micropustule of Kogoj in the upper epidermis. She was diagnosed as having uveitis with psoriasis vulgaris. HLA typing revealed that she had the genotype 111^A2, -A24, -B51, -Cwl and -Cw3. Cyclosporin A at 5 mg/kg per day for 2 weeks, led to considerable improvement in the uveitis and eruption. Hatchome and Tagami reported a similar. HLA-B5-positive, patient who had hypopyon-iridocyclitis associated with an exacerbation of pustular psoriasis and arthralgia.' HLA-B5 is now clessitied as HLA-Bw51 or -Bw52. indicating that their patient may also have possessed HLA-B51, a gene considered to encode for a susceptibility to Behget's disease, in which uveitis is a major symptom. Although psoriasis and Behget's disease differ, they have some similarities in symptoms and pathugenesis. Both may be triggered by infectious episodes such as dental disease or tonsillitis, and both may be accompanied by arthralgia. Common factors in the pathogenesis include enhanced leucocyte chemotaxis.*'^ HLA class I association—HLA-B51 in Behc;et's disease.*" and HLA-Cwf) in psoriasis vulgaris.' Thus, a common pathogenesis may be present in each disease, and HLA-B51 may be a risk factor for uveitis in psoriasis. DeparUnent of Dermatologi). Hiroshima University School of Medicine. Kasumi 1-2-^. Minami-ku. Hiroshima 7M. Japan *Departinenl of Dermatology. Hiroshima General Hospital, .Jigozett I-3-3, Hiitsiikaifhi 738. Japan

© 1997 British Association of Dermatologists. British Jourmil of Derimitolonfj. 1 ?(>. 9 6 8 - 9 8 1

E.MORITA S.SATO* S-YAMAMOTO