Immunohistochemical findings in granuloma faciale. The role of eosinophilic granulocytes

Granuloma Faciale and Eosinophilic Angiocentric Fibrosis: Similar Entities in Different Anatomic Sites

BACKGROUND

Eosinophilic angiocentric fibrosis (EAF) and granuloma faciale (GF) share several histopathologic features, including eosinophil-rich inflammation, microangiitis, and progressive fibrosis. Concurrent presentation of EAF and GF suggests a pathogenetic link between them.

OBJECTIVES

To identify histologic findings that tell them apart and construe the pathogenetic mechanisms behind each morphologic variable, 14 immunohistochemical markers were used to study the cells subpopulations in 14 cases of GF and 3 cases of EAF.

MATERIALS AND METHODS

The lesions were classified according to their stage of development. The antibodies studied were: CD4, Foxp3, CD8, granzymes A and B, perforin, granulysin, CD20, CD56, CD68, ICAM-1, CD34, CD105, and 1A4.

RESULTS

The intensity of the sclerotic response and the density of 1A4-immunostained cells were significantly higher in EAF. In both diseases, CD68 cells were the most numerous, followed by CD20, CD8, and CD4 cells. About 30% of cells expressed ICAM-1. Among cells with cytotoxic granules, granulysin-positive cells were the most frequent.

CONCLUSIONS

Differences between GF and EAF were found to be mostly like due to anatomic site (usually skin of the face vs. sinonasal cavity) and stage of the disease development (usually earlier in cutaneous lesions because of their visibility). Innate and adaptive immunity, including B cells, T cells, and cytotoxic granules have a role in their pathogenesis.

The interaction of inflammatory cells in granuloma faciale

Granuloma faciale (GF) is a rare chronic inflammatory skin disease characterized by single or multiple reddish-brown cutaneous plaques or nodules. Although this condition is benign, its clinical course is extremely chronic with poor response to therapy. The typical histopathological features of GF include vasculitis with mixed cellular infiltration; however, its etiopathogenesis remains unknown. Here, we describe the case of a 76-year-old man with GF resistant to topical steroids. Biopsy of the lesion revealed i) dense mixed inflammatory cellular infiltrates of lymphocytes, histiocytes, neutrophils, and eosinophils, ii) mild perivascular nuclear dust and swollen endothelium of blood vessels, and iii) a narrow Grenz zone beneath the epidermis. Immunohistochemical staining demonstrated mixed cellular infiltrates intermixed with CD1a⁺ dendritic cells, CD68⁺ histiocytes, and CD4⁺ and CD8⁺ T cells.

Granuloma faciale: Is it a new indication for pimecrolimus? A case report

Granuloma faciale is a benign, chronic disease which is characterized by red-brown facial nodules and plaques. This quite rare disease is mostly seen in middle-aged males. A 41-year-old female patient consulted our department with a facial lesion of 4 years' duration. A dermatological examination revealed a pink-brown plaque of 1x5 cm over the nasal dorsum extending to the left malar region. Her personal and family histories were unremarkable. The routine hemogram and biochemical tests were normal, antinuclear antibody was negative. In the histopathological examination of the biopsy material which was taken from the lesion, the epidermis was intact; grenz zone was observed in the papillary dermis and with diffuse infiltrate with leukocytoclastic vasculitis and eosinophils, polymorphonuclear leukocytes and lymphocytes in the dermis were observed. With these findings, the patient was diagnosed with granuloma faciale and treatment with topical pimecrolimus cream 1% was started. The patient applied this treatment twice a day for 2 months and a dramatic recovery was observed after this period. The case is discussed in comparison with the literature.

Granuloma faciale with extrafacial lesions

A 35-year-old man presented with a 7-year history of gradually enlarging plaques on his face and trunk. The first lesions had developed on both sides of the forehead and the left cheekbone (Figure 1). Four years later similar lesions appeared on his neck and back. He presented a histologic report of a biopsy specimen from a facial plaque performed 5 years earlier that was diagnostic for granuloma faciale. He had different treatments such as topical steroids and cryotherapy without improvement. The appearance of new lesions on his trunk and the gradual enlarging of the old lesions convinced the patient to seek further treatment. Physical examination revealed dusky, violaceous plaques and papules, 0.5 to 2 cm, well-circumscribed, slightly elevated, and located on the face and trunk, with mild pruritus (Figure 1 and Figure 2). Laboratory investigations, including complete blood cell count, VDRL test, antinuclear antibody test, biochemical parameters, and chest x-ray, did not reveal any abnormalities. A skin biopsy taken from the upper part of the back showed similar features to the facial lesion, detected 5 years before, revealing a dense, polymorphous infiltrate involving mid and deep dermis and displaying a diffuse and perivascular pattern (Figure 3A). A narrow grenz zone of normal collagen was consistently observed between dermal infiltrate and epidermis as well as around the pilosebaceous follicles (Figure 3A). The infiltrate mainly consisted of eosinophils and lymphocytes, but neutrophils (often displaying leukocytoclasis), macrophages, and plasma cells were also present (Figures 3B, 3C). Some mast cells were also identified by staining with toluidine blue (Figure 3D). Perivascular infiltrates were often seen, sometimes penetrating vessel walls and in association with leukocytoclasis. Hyalinization of vessel walls, extravasation of red blood cells around capillaries, and nuclear dust were also noted. The epidermis did not show any remarkable change except for slight acanthosis. A diagnosis of granuloma faciale with extrafacial lesions was made, and a systemic therapy with hydroxychloroquine (200 mg twice daily for 6 weeks) was recommended.(1,2).