Collagen-elastic tissue changes and vascular involvement in granuloma annulare: a review of 35 cases

Spatial transcriptomics reveals organized and distinct immune activation in cutaneous granulomatous disorders

BACKGROUND

Noninfectious (inflammatory) cutaneous granulomatous disorders include cutaneous sarcoidosis (CS), granuloma annulare (GA), necrobiosis lipoidica (NL), and necrobiotic xanthogranuloma (NXG). These disorders share macrophage-predominant inflammation histologically, but the inflammatory architecture and the pattern of extracellular matrix alteration varies. The underlying molecular explanations for these differences remain unclear.

OBJECTIVE

We sought to understand spatial gene expression characteristics in these disorders.

METHODS

We performed spatial transcriptomics in cases of CS, GA, NL, and NXG to compare patterns of immune activation and other molecular features in a spatially resolved fashion.

RESULTS

CS is characterized by a polarized, spatially organized type 1-predominant response with classical macrophage activation. GA is characterized by a mixed but spatially organized pattern of type 1 and type 2 polarization with both classical and alternative macrophage activation. NL showed concomitant activation of type 1, type 2, and type 3 immunity with a mixed pattern of macrophage activation. Activation of type 1 immunity was shared among, CS, GA, and NL and included upregulation of IL-32. NXG showed upregulation of CXCR4-CXCL12/14 chemokine signaling and exaggerated alternative macrophage polarization. Histologic alteration of extracellular matrix correlated with hypoxia and glycolysis programs and type 2 immune activation.

CONCLUSIONS

Inflammatory cutaneous granulomatous disorders show distinct and spatially organized immune activation that correlate with hallmark histologic changes.

Erythematous brownish plaques with an annular configuration

Granuloma annulare (GA) and cutaneous sarcoidosis show clinicopathological overlap and they are also aetiopathogenically related. Given the similarities of sarcoidal GA and sarcoidosis, and the reports of association of sarcoidal GA with systemic sarcoidosis, this diagnosis should prompt further investigation to exclude systemic involvement. Being aware of the subtle histopathological clues is of the utmost importance for an accurate diagnosis of this rare variant, but correlation with the clinical setting and use of ancillary investigations are also warranted to confidently exclude sarcoidosis.

Is biologic therapy the future of granuloma annulare treatment?

Granuloma annulare (GA) is a benign inflammatory skin disease that presents with erythematous papules and annular plaques. The pathogenesis of GA remains unknown and may potentially involve type 1 T helper cell (Th1)-mediated delayed-type hypersensitivity reaction. GA is associated with many conditions such as malignancy, trauma, thyroid disease, diabetes mellitus, and viral infection. The role of biological treatment is under investigation. In this article, we present a case of GA development following systemic treatment of psoriatic arthritis in a 59-year-old patient; golimumab therapy resulted in the successful treatment of both psoriatic arthritis and GA. This is the first case report describing GA therapy using golimumab.

Non-Infectious Granulomatous Dermatoses: A Pathologist's Perspective

Granulomatous dermatitis (GD) is one of the commonest tissue reaction patterns encountered in dermatopathology practice. Granulomatous inflammation in the skin can be seen in a wide range of conditions, thus, granulomatous dermatitis always poses significant challenge even to the astute dermatologists and dermatopathologists. Broadly, granulomatous dermatitis is divided into two groups-infectious and non-infectious, the prevalence of both highly variable and show overlapping pathology. However, there are subtle histological clues, which when combined with clinical features, help to narrow down the differential diagnosis. Thus, a good Clinicopathological correlation (CPC) along with histochemical stains, culture and ancillary techniques including molecular studies are required for arriving at a definite diagnosis. In this review, we shall discuss the histological clues to diagnose non-infectious granulomatous dermatitis (NIGD) and their differential diagnoses.

Palisading granulomatous dermatitis and panniculitis (palisading granuloma) of dogs

Palisading granulomatous dermatitis and panniculitis is recognized in various cutaneous inflammatory lesions secondary to presumed collagen damage. Cutaneous nodules with a palisading arrangement of histiocytes surrounding foci of collagen degeneration have been clinically termed palisading granuloma in dogs. Study aims were to characterize the cellular infiltrate of canine palisading granuloma and document salient clinical features. Inclusion criteria were met for 36 dogs and encompassed nodular dermal and subcutaneous histiocyte-predominant cellular infiltrates targeting and enveloping collagen fibers/necrotic foci with palisading configurations. Infectious causes were ruled out via standard histochemical stains and/or clinical data. Medical records were reviewed for signalment, clinical features, treatment, outcome, and comorbidities. Immunohistochemistry (IBA1, CD204, E-cadherin) and Masson's trichrome stain were used to assess histiocytic populations and dermal collagen, respectively. The histiocytes had moderate or strong immunolabeling for IBA1 and CD204 in 36/36 dogs (100%) and mild positive immunolabeling for E-cadherin in 3/36 dogs (8%). Alteration of collagen was graded as moderate or strong in 32/36 dogs (89%) and mild in 3/36 dogs (8%). Large breeds predominated with 30/36 dogs (83%) being ≥23 kg. Focal nodules were identified in 31/36 dogs (86%). The head/face were involved in 19/36 dogs (53%) and the extremities in 18/36 dogs (50%). Lesions from the 5/36 dogs (14%) with multiple nodules contained prominent eosinophilic infiltrates. Following excision, there was no evidence of recurrence. In conclusion, palisading granulomas are a distinct, non-neoplastic, histiocyte-predominant inflammatory condition in dogs associated with altered dermal collagen and favorable prognosis.

[Generalized granuloma annulare: A clinicopathological study]

BACKGROUND

Granuloma annulare (GA) is a benign granulomatous skin disorder that is generalized (GGA) in 15 % of cases. Although many case reports describe a relationship between GGA and systemic diseases, few large series have been published, and their association is debated. We present herein a series of GGA in order to describe their clinical and histological features.

PATIENTS AND METHODS

We included all biopsy-proven cases of GA presenting at the dermatopathology laboratory of Strasbourg where generalized (i.e. over 10 lesions). Clinical features were obtained from patients' medical files.

RESULTS

We included 35 GGA, with a sex ratio of 0.5. The mean age was 54 years. Lesions were annular or non-annular in equal measure and were symptomatic in 25 % of cases. Most patients (77 %) had an associated disease, already known in 60 % of cases, including dyslipidemia (27 %), diabetes mellitus (20 %), immunosuppressive drugs (17 %), atopy (17 %), auto-immune disease (17 %), hematological disease (14 %), and cancer (9 %). Histological analysis revealed the predominant pattern to be interstitial (54 %) rather than palisading (20 %), having no correlation with clinical type. Eosinophils were frequent (46 %) in GA but were not correlated with systemic disease or drug taking. Among the 40 % of patients treated, 50 % had a successful outcome on topical corticosteroids, doxycycline, antimalarial drugs or phototherapy.

DISCUSSION

GGA differs from localized GA, which is mostly associated with an already known systemic disease, whether metabolic, infectious or neoplastic, uncorrelated with clinical or histological features, and screening is necessary.

[Experience with fractional photothermolysis in the therapy of gra-nuloma annulare]

BACKGROUND

Granuloma annulare is a benign inflammatory dermatosis of unknown etiology, which is characterized by the development of flesh-colored or red papules often arranged in rings on the skin. Currently there are no effective treatments for granuloma annulare. Topical and intradermal applications of glucocorticosteroids produce a short-term and insufficient therapeutic effect. The method cannot be used in extensive rashes. Fractional photothermolysis is a physical method for ablative exposure of tissues to an erbium laser via their local heating with light energy in certain areas.

AIM

To investigate the efficiency of fractional photothermolysis in the therapy of patients with granuloma annulare.

MATERIAL AND METHODS

Twenty-eight patients diagnosed with granuloma annulare were followed up. All the patients were treated with fractional Fotona Fidelis XS erbium laser at a wavelength of 2940 nm using a FS01 maniple. The treatment cycle consisted of 5 sessions.

RESULT

After the treatment, the GASI index was decreased by 50, 75, and 100% in 5 (17.9%), 15 (53.6%), and 8 (28.6%) patients, respectively. The median GASI index was decreased by a total of 2.8 times (p<0.05).

CONCLUSION

The study showed the high efficiency of fractional photothermolysis in the treatment of patients with granuloma annulare. This method can be recommended for the treatment of common forms of granuloma annulare.

Evaluating the Unusual Histological Aspects of Granuloma Annulare: A Study of 30 Cases

BACKGROUND

Granuloma annulare (GA) is an uncommon dermatologic disorder that presents as annular, skin-colored to erythematous plaques. Histopathologically, it is characterized by palisaded histiocytic granulomas. A definitive diagnosis of GA is based on clinicopathologic correlation.

OBJECTIVE

The aim of this study was to study the histomorphologic spectrum of GA.

MATERIALS AND METHODS

A total of 30 cases reported as GA over 6 years (2012-2017) were retrieved. The detailed clinical profile and histomorphologic findings on the skin biospies were reviewed.

RESULTS

Majority of the cases (40%) presented in the 6th decade of life with a mean age of 48.3 ± 16.5 years and with a female predominance (77%). The lesions were localized in 22 cases (73%). Asymptomatic to erythematous, annular plaques was the most frequent presentation (60%). GA was not suspected clinically in two cases. Histopathologically, interstitial pattern of infiltrate was most common (44%), whereas granuloma formation and palisaded histiocytes were seen in 4 (13%) and 3 cases (10%), respectively. A mixed pattern was observed in 10 (33%) cases. Collagen degeneration was universal finding (100%) and presence of dermal mucin was noted in 24 cases (80%), both of which were important clues to the diagnosis of GA. Additional features such as presence of plasma cells, eosinophils, and vasculitis were noted in 10 (33%), 6 (20%), and 6 (20%) cases, respectively.

CONCLUSION

The diagnosis of GA may be challenging owing to its diverse morphology. Acquaintance with the varied histomorphology of GA is of utmost importance to render a correct diagnosis and understand the pathogenesis.

Immune response patterns in non-communicable inflammatory skin diseases

Non-communicable inflammatory skin diseases (ncISD) such as psoriasis or atopic eczema are a major cause of global disease burden. Due to their impact and complexity, ncISD represent a major challenge of modern medicine. Dermatology textbooks describe more than 100 different ncISD based on clinical phenotype and histological architecture. In the last decades, this historical description was complemented by increasing molecular knowledge - and this knowledge is now being translated into specific therapeutics. Combining the enormous advances made in lymphocyte immunology and molecular genetics with clinical and histological phenotyping reveals six immune response patterns of the skin - type I immune cells cause the lichenoid pattern characterized by immune-mediated cell death of keratinocytes; type II immune cells underlie the eczematous pattern with impaired epidermal barrier, infection and eosinophils as well as the bullous pattern with loss of epithelial integrity; Th17 cells and ILC3 mediate the psoriatic pattern characterized by acanthosis, high metabolic activity and neutrophils; dysbalance of regulatory T cells causes either the fibrogenic pattern with rarefication of cells and dermal thickening or the granulomatous pattern defined by formation of granulomas. With more and more specific therapeutic agents approved, classifying ncISD also according to their immune response pattern will become highly relevant. This review defines the six immune response patterns of ncISD and highlights therapeutic strategies targeting key lymphocyte mediators.

Granuloma Annulare Skin Lesions in a Case of Sarcoidosis

We report the case of a 32-year- old man with a short 3-week history of erythematous, annular, non scaly plaques on palmar and dorsal aspect of his hands, who was concurrently diagnosed as a case of sarcoidosis on the basis of findings of generalized lymphadenopathy and radiological and histological features of pulmonary sarcoidosis. His skin biopsy was consistent with the diagnosis of granuloma annulare. Sarcoidosis and granuloma annulare are two separate diseases, which involve the skin and have a mononuclear histiocytic cellular reaction, although their aetiology is still unknown. Granuloma annulare has been associated with the concomitant diagnosis of sarcoidosis in only two more case reports and this association can be evaluated further to study a common link in the aetipathogenesis of these two granulomatous skin diseases.

Granuloma annulare treated with narrowband UVB phototherapy

Granuloma annulare is a benign cutaneous inflammatory disease, whose lesions have spontaneous improvement in two years in 50% of cases, but there is recurrence in 40% of patients. Treatment may be topical, intralesional or systemic. The use of phototherapy with narrowband UVB is highlighted, whose mechanism of action in this disease is still unclear, probably related to the inhibition of T lymphocytes. Herein, a case of a disseminated granuloma annulare of difficult therapeutic management is described. It was treated with narrowband UVB phototherapy twice a week for six months, with good clinical improvement, being a good low-risk therapeutic option and that, in this case, provided quick and satisfactory response.

Granuloma annulare: Clinical and histologic variants, epidemiology, and genetics

Granuloma annulare (GA) is a poorly understood condition characterized by a set of clinical morphologic variants with 2 predominant histopathologic patterns of inflammation. This review provides a comprehensive overview of the available information about the clinical variants and histopathologic features, current epidemiologic data, and potential genetic underpinnings of GA. Much of the current understanding of GA is based on retrospective studies, case series, and case reports; this review aims to synthesize the available information and present it clearly for practicing dermatologists.

Chronic Hepatitis with Liver Granulomas in a Patient with Granuloma Annulare: A Case Report and Review of the Literature

Granuloma annulare (GA) is a benign granulomatous skin disorder of unknown etiology. GA is rarely associated with liver diseases. We report a unique case of chronic hepatitis with liver granulomas in a patient with GA. Despite an extensive workup, no clear etiology for the hepatitis was found. Based on the possible immune pathophysiology of GA and the presence of liver granulomas, the patient was treated with prednisone and azathioprine which resulted in complete normalization of the liver enzymes and concurrent improvement of GA. The association between liver diseases and GA is reviewed.

Intraorbital granuloma annulare in an elderly patient

Classically, granuloma annulare (GA) is a cutaneous disorder localized to the dorsum of the hands and/or feet in children and young adults. Very rarely it can present on the face and rarer still on periorbital structures such as the eyelid and orbital rim. Diagnosis hinges on clinical presentation and histological features, such as palisading granulomas with central destruction of collagen, presence of mucin and lymphohistiocytic infiltration. The etiology of this condition remains unknown, but may involve a delayed-type hypersensitivity reaction, malignancy and/or infection. Herein is the first reported case of an intraorbital GA in an 86-year-old male patient who presented with right eye proptosis.

Comedones Induced by Vascular Laser Therapy

A 21-year-old female presented with acne-like blackheads on brownish areas located on the cheek. She had been treated with neodymium-doped yttrium aluminium garnet (Nd-YAG) laser (1071 nm), 160 j/cm², three months ago for erythema and telangiectasia of her face. Afterwards, she developed atrophic, slightly depressed, hyperpigmented, 3-4 mm scars with superimposed tiny comedones within the treated areas. Topical treatment with tretinoin 0.05% cream on alternate days, and Sun Protection Factor (SPF) 50 sunscreen daily were commenced. After 2 months, comedones and hyperpigmentation mostly resolved but mild superficial atrophy persisted. According to our knowledge, this is the first case of atrophic scars studded with open comedones, developing shortly after laser therapy used for facial telangiectasia.

Histologic features of granulomatous skin diseases. Part 1: Non-infectious granulomatous disorders

Granulomatous disorders affecting the skin belong to a heterogeneous group of diseases. With the exception of granulomas induced by infectious agents or foreign bodies, the etiopathogenesis of granulomatous disorders is still poorly understood. The knowledge of histopathologic changes is of great importance for understanding clinical presentation and disease course.

The efficacy of PUVA and narrowband UVB phototherapy in the management of generalised granuloma annulare

Generalised granuloma annulare (GGA) is a significant cosmetic issue for patients but evidence is lacking to guide optimum treatment. We reviewed our patients with GGA treated with PUVA and narrowband UVB (NBUVB). A telephone questionnaire obtained the patients' perspective in terms of treatment response, remission and overall satisfaction. Twenty patients, all female, were treated. Twelve patients had 15 courses of PUVA therapy (10 oral, 5 bath PUVA) and 10 had 12 courses of NB UVB (two patients had both). There was clearance or minimal residual disease (MRD) on clinical examination in eight of 12 patients after PUVA. Remission was for six months in seven patients extending to one year or more in five patients. Nine patients were contactable after PUVA therapy. They reported their satisfaction as excellent (n = 1), very good (n = 2) or good (n = 4), and two were disappointed. There was clearance or MRD in seven patients treated with NBUVB. Remission was for six months in at least three patients and greater than 1 year in at least 2 patients. Eight patients were contactable and reported satisfaction as excellent (n = 1) or good (n = 5) and two were disappointed. PUVA and NBUVB were effective in at least half of patients and they achieved satisfactory remission. Patients' perceptions of the improvement after phototherapy were lower compared with their dermatologists' assessment.

Interstitial granulomatous dermatitis associated with systemic lupus erythematosus: case report and review of the literature

Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease of unknown etiology that most frequently involves the skin and the musculoskeletal system. In addition to the more common cutaneous manifestations, interstitial granulomatous dermatitis (IGD) may rarely occur in association with SLE or even be the first sign of the disease. We describe a 40-year-old man with SLE-associated IGD, and review all cases of SLE-associated IGD in the literature.

Clinical and morphological features of elastolytic granulomas

The authors discuss current data on the classification, etiology and pathogenesis, clinical picture, pathologic features and treatment options of elastolytic granulomas (EGs). The authors disclose main aspects of elastolysis and elastophagocytosis development. Three cases of diseases from the EG group - actinic granuloma and annular elastolytic giant cell granuloma -are described for the first time in the Russian literature.

Granuloma annularis revealing Wegener's granulomatosis

Skin manifestations are often associated with systemic autoimmune diseases (SAD). Some SAD, such as systemic lupus erythematosus, psoriatic arthritis and scleroderma display pathognomonic dermatological features, whereas other systemic diseases such as sarcoidosis, vasculitis and rheumatoid arthritis can present with non-specific skin manifestations that range from erythema nodosum to necrotic lesions. Here we report the case of a 25-year-old man with uveitis, polyarthrirtis, pulmonary involvement, nephrotic syndrome, cutaneous granuloma and pneumonia by E. coli.

Etiology, diagnosis, and therapeutic management of granuloma annulare: an update

Granuloma annulare (GA) is a common cutaneous disorder classically presenting as annular groups of skin-colored to erythematous papules without epidermal change localized to the dorsal hands and/or feet. In addition to the localized form, there are variants including generalized (including generalized annular GA, disseminated papular GA, and atypical generalized GA), subcutaneous, and perforating GA, providing for a wide spectrum of clinical lesions. The etiology of GA remains unknown and several systemic associations have been proposed but not proven, including diabetes mellitus, malignancy, thyroid disease, and dyslipidemia. The diagnosis of GA relies on clinicopathological correlation, with a skin biopsy confirming the histological features of the disease, including palisading granulomas, collagen degeneration, mucin, and a lymphohistiocytic infiltrate. Localized GA is often asymptomatic and self-limited within 2 years; however, the patient may desire treatment for cosmetic reasons, with topical and intralesional corticosteroids as the mainstays of therapy. When GA is generalized, disseminated, or atypical, a more thorough medical workup for underlying diseases may be considered depending on the physical examination, a thorough review of systems, comorbidities, and clinical suspicion. Treatment is often challenging for generalized GA, especially because of its recalcitrant nature and a lack of evidence-based therapy. Over 30 different treatments have been described for GA with variable results; however, the majority of these have been single case reports, small case series, or retrospective studies. Reported treatments for GA include topical, intralesional, intramuscular, and oral medications (steroidal vs. non-steroidal); biologic agents; surgical interventions; phototherapy; and laser treatments. When selecting a systemic therapy for a patient with GA, multiple variables must be considered, such as baseline blood evaluations, comorbidities, drug interactions, compliance, adverse effect profiles, prior treatments, and reproductive status. This evidence-based review will focus on the advances made in the twenty-first century regarding the etiology, diagnosis, and therapeutic management of GA.