[Annular elastolytic giant cell granuloma with a spontaneous healing tendency]

Granulomatous slack skin syndrome: Report of a unique case

Granulomatous slack skin syndrome is a rare variant of cutaneous T-cell lymphoma (mycosis fungoides). It is characterized clinically by redundant skin folds, which show a predilection towards flexural areas such as the axilla and the groin. Histologically, it shows a granulomatous T-cell infiltrate and loss of elastic tissue. It has an indolent but progressive course; and is usually refractory to treatment. We report a unique case of slack skin syndrome, sparing the classical sites with rapid and unusual involvement of non-intertriginous areas.

A Case of Annular Elastolytic Giant Cell Granuloma Associated with Syphilis

Annular elastolytic giant cell granuloma (AEGCG) is a rare granulomatous skin disease characterized by annular patches with slightly raised borders, hypopigmented and/or atrophic centers found mainly on sun-exposed skin. Histologically, it is characterized by phagocytosis of elastic fibers by multinucleated giant cells. The pathogenesis of the disease is unclear. We report a case of 55-year-old man with AEGCG in association with syphilis, whose condition improved when hydroxychloroquine sulfate and topical tacrolimus were administered over a 2-month period.

Annular elastolytic giant cell granuloma in association with Hashimoto's thyroiditis

Annular elastolytic giant cell granuloma (AEGCG) is a rare granulomatous skin disease characterized clinically by annular plaques with elevated borders and atrophic centers found mainly on sun-exposed skin and histologically by diffuse granulomatous infiltrates composed of multinucleated giant cells, histiocytes and lymphocytes in the dermis along with phagocytosis of elastic fibers by multinucleated giant cells. We report a case of AEGCG in a 50-year-old woman and is highlighted for the classical clinical and histological findings of the disease and its rare co-existence with Hashimoto's thyroiditis.

[Annular elastolytic giant cell granuloma]

BACKGROUND

Annular elastolytic giant cell granuloma (AEGCG) is a rare form of granulomatous dermatosis. It is characterised histologically by phagocytosis of elastic fibres by multinucleated cells. We report a favourable outcome in a case of AEGCG following PUVA therapy and treatment with synthetic antimalarials.

PATIENTS AND METHODS

A 67-year-old retired wine grower presented with highly pruritic annular lesions with raised borders on the shoulders and trunk that had been present for several months. Histological examination of a biopsy sample from the erythematous border was characteristic of AEGCG. Various topical treatments proved ineffective and systemic corticosteroids attenuated the patient's pruritus but had no effect on the skin lesions. PUVA therapy resulted in regression of lesions on the trunk, but the rash spread to the patient's arms and was covered with epidermal microcysts. PUVA therapy was discontinued and treatment with a synthetic antimalarial (hydroxychloroquine 400mg/d) was initiated, resulting in complete regression of the lesions.

DISCUSSION

AEGC was isolated in 1979 by Hanke et al. on the basis of five cases seen in females. This is a rare form of dermatosis with some 30 cases being reported in the English literature. The clinical aspect is fairly evocative, with erythematous papular lesions, either alone or in groups, with a raised border and a lighter centre tending towards atrophy. In most cases, the lesions are found predominantly in areas exposed to sunlight. The histological appearance is characteristic, with an image of giant cell elastophagic granuloma from which the name of the disease is taken. This appearance allows the disease to be differentiated from a number of other granulomatous diseases. The aetiology is unknown and treatment is empirical. Spontaneous cure can occur and consistent results have not been obtained with any treatments. In our case, PUVA was partly successful, and the synthetic antimalarials resulted in complete regression of residual lesions.

Granulomatous slack skin without evidence of a clonal T-cell proliferation

Granulomatous slack skin is a rare cutaneous disorder with less than 50 cases presented in the English-language literature. The disease is characterized by circumscribed erythematous lax skin accentuated most commonly in the axillary and inguinal areas. A strong association with a preceding or evolving diagnosis of mycosis fungoides or Hodgkin's disease has been reported. Previous reports describe the entity as a lymphoproliferative disease in the same spectrum as mycosis fungoides and Hodgkin's disease with a monoclonal T-cell population. Our case, without an evident beta-T-cell receptor rearrangement, suggests that not all cases of granulomatous slack skin are a result of an indolent lymphoma. Granulomatous slack skin probably represents a spectrum of diseases that can eventuate into a lymphoproliferative process.

A case of primary cutaneous CD30+ T-cell lymphoproliferative disorder with features of granulomatous slack skin disease

We present a patient with primary CD30+ cutaneous T-cell lymphoma whose histological and clinical features overlapped with those of granulomatous slack skin disease (GSSD). A 26-year-old woman had infiltrative erythema on the abdominal wall and an incurable ulcerative lesion on the left knee. Her skin progressively became atrophic and pendulous, showing a hyperpigmented appearance over almost the whole body. Histopathologically, a dense lymphoid cell infiltrate accompanying numerous macrophages and multinucleated giant cells (MGC) extended into the subcutaneous tissue. Most lymphoid cells were small and positive for T-cell markers. Some relatively large atypical cells were scattered in the lesion, most of which (60%) were positive for CD30. T-cell receptor-beta gene rearrangement was confirmed in the abdominal lesion. MGC infiltrated more dominantly into a deeeper layer of the skin with the elastic fibres there almost completely disappearing. Immunoreactivity for CD30 of MGC was negative and overexpression of elastolytic metalloproteinases was observed. The association between primary cutaneous CD30+ lym- phoproliferative disorders and GSSD has not previously been reported. Overexpression of elastolytic metalloproteinases in MGC contributes to the disappearance of the elastic fibres and enhances the severity of the clinical course.

Annular elastolytic giant cell granuloma: sparing of a burn scar and successful treatment with chloroquine

Annular elastolytic giant cell granuloma is a rare granulomatous skin disease characterized by phagocytosis of elastic fibres by multinucleated giant cells. Lesions are either solitary or grouped in a few annular patches with elevated borders and central atrophy. Sun-exposed areas are more commonly involved than covered skin. The pathogenesis of the disease is still controversial. We report a 72-year-old fair-skinned woman with unusual clinical findings. An irregularly shaped erythematous plaque covered the entire face, and hundreds of lichenoid papules were present on both sun-exposed and covered areas which gradually evolved into annular lesions of about 0.5-1 cm in diameter. Sparing of an old burn scar and a nearly complete lack of elastic fibres in the scar site were noted, illustrating the presumed importance of dermal elastic tissue in the pathogenesis. The course of the disease is chronic. Several treatments have been tried, with variable success. In our patient, improvement was achieved with chloroquine over a period of 16 weeks.