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Granuloma faciale
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Granuloma faciale is a rare, benign, chronic inflammatory dermatosis caused by a localized form of cutaneous vasculitis. It presents primarily in middle-aged Caucasian males, usually as an asymptomatic single lesion on the face. Extensive involvement of the nose can mimic rhinophyma. Multiple lesions occur in up to one-third of patients. Extrafacial granuloma faciale is rare and usually found in association with facial lesions. The etiology of granuloma faciale is unclear.
Lesions are red-brown, violaceous, or flesh-colored plaques or nodules with accentuation of follicular openings giving a ‘peau d’orange’ appearance. Clinical diagnosis is difficult. Differential diagnosis includes sarcoid, lupus, lymphocytoma cutis, persistent insect bite reactions, leishmaniasis, and lymphoma. The histologic differential diagnosis includes erythema elevatum diutinum and angiolymphoid hyperplasia with eosinophilia.
Management Strategy
Granuloma faciale is notoriously resistant to treatment and spontaneous remission is unusual. Because it is rare, there are no formal trials of therapy. Treatment modalities can be divided into destructive techniques ( cryotherapy , laser , surgical excision ) and antiinflammatory approaches. The optimal treatment depends on the size and extent of lesions.
Granuloma faciale treatment: a systematic review
Lindhaus C, Elsner P. Acta Derm Venereol 2018; 98: 14–8.
In the last few years, there have been increasing numbers of case reports of successful treatment with topical calcineurin inhibitors for isolated or multiple lesions, and a recent systematic review of 94 patients recommended this as first-line treatment and pulsed-dye laser for drug-resistant lesions.
Histologic findings include a dense eosinophilic and neutrophilic infiltrate, often perivascular, affecting the upper and sometimes deep dermis. The epidermis is spared, and there is a grenz zone. Telangiectasia is common. Vasculitis with leukocytoclasis is reported. Dermal fibrosis is often seen.
Granuloma faciale: a clinicopathologic study of 66 patients
Ortonne N, Wechsler J, Bagot M, et al. J Am Acad Dermatol 2005; 53: 1002–9.
Peripheral blood eosinophilia is sometimes found.
Dermoscopic patterns of common facial inflammatory skin disease
Lallas A, Argenziano G, Apalla Z, et al. J Eur Acad Dermatol Venereol 2014; 28: 609–14.
Dermoscopy is increasingly used to aid diagnosis in granuloma faciale. Follicle abnormalities such as dilated follicular openings, perifollicular whitish halo, follicular keratotic plugs, and linear slightly arborizing vessels in a parallel arrangement are the most commonly described dermoscopic criteria.
Granuloma faciale treated with intradermal dexamethasone
Arundell FD, Burdick KH. Arch Dermatol 1960; 82: 437–8.
This paper reports response to dexamethasone, but triamcinolone acetonide and triamcinolone hexacetonide have also been used. Patients should be warned of the risk of skin atrophy and pigment change.
Granuloma faciale: is it a new indication for pimecrolimus? A case report
Eetam I, Ertekin B, Unal I, et al. J Dermatol Treat 2006; 17: 238–40.
A case report of a lesion showing ‘dramatic recovery’ after pimecrolimus cream 1% twice daily for 2 months.
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