Autoimmunity-related granulomatous dermatitis in association with hepatitis

Interstitial Granulomatous Dermatitis and Palisaded Neutrophilic Granulomatous Dermatitis: Retrospective Clinicopathological Analysis of 16 Cases

INTRODUCTION

Reactive granulomatous dermatitis (RGD) is a new entity, which is highly associated with systemic disorders. There is scarce data regarding interstitial granulomatous dermatitis (IGD) and palisaded neutrophilic granulomatous dermatitis (PNGD).

OBJECTIVES

We aimed to evaluate clinical and histopathological characteristics of IGD and PNGD as unified entities under the term of RGD.

METHODS

Observational, retrospective, single-center study of patients diagnosed with IGD and PNGD between 2012 and 2021 were included in the study.

RESULTS

Of 16 patients (14 females and 2 males) with RGD, 13 had IGD and 3 had PNGD with a mean age of 62.5 years. The most common clinical presentation was plaques 37.5% (N=6), followed by patches 25% (N=4). The most common localization of involvement was lower extremity 75% (N=12), followed by trunk and upper extremity. Multiple localization of involvement was determined in 75% (N=12) of patients. None of the patients had rope sign. Associated comorbidities such as autoimmune diseases and malignancies were detected in 68.7% (N=11) of patients. In majority of biopsies (87.5%; N=14), there were lymphohistiocytic cell infiltration. Other accompanying cells were scarce neutrophils 31.2% (N=5) and eosinophils 31.2% (N=5). All of the biopsies had interstitially located lymphohistiocytic cell infiltration surrounding with swollen and degenerated collagen. Palisaded pattern was determined in 18.7% (N=3) of patients and floating sign was seen in 18.7% (N=3) of biopsies.

CONCLUSIONS

RGD is a rare entity and most patients with RGD had associated disorders such as autoimmunity or malignancy. There is overlapping between IGD and PNGD, therefore supporting the usage of umbrella term as reactive granulomatous dermatitis is compatible with the literature.

Granulomatous Dermatitis and Systemic Disease: An Association to Consider

Granuloma annulare (GA) and interstitial granulomatous dermatitis (IGD) are granulomatous dermatoses with variable clinical appearances. GA is associated with diabetes mellitus, metabolic syndrome, chronic infections, and malignancies, while two Japanese reports described unusual cases of interstitial-type GA in setting of Sjogren syndrome. IGD was associated with rheumatoid arthritis, systemic lupus erythematosus, and autoantibodies. We report a case series of six patients with GA or IGD. Half of the patients were diagnosed with Sjogren syndrome, while all of them presented ANA positivity and the majority reported arthralgia. In many cases, GA showed interstitial-type histology, arising challenges in differential diagnosis with IGD. The overlap of clinical and histological features of GA and IGD can be explained considering them as a broad disease spectrum, including also the other forms of reactive granulomatous dermatitis. These conditions should be considered as an indicator of possible systemic disorders or other immunological dyscrasias, for which patients must be screened. Sjogren syndrome may be associated to GA also in Caucasians.

Palisaded Granulomatous Dermatitis Associated with Ulcerative Colitis: A Comprehensive Literature Review

Palisaded granulomatous dermatitis is an uncommon pathologic condition potentially associated with several disorders. These include drugs, inflammatory bowel disease, multiple myelomas, rheumatoid arthritis, and systemic lupus erythematosus. An illustrative case of a man with palisaded granulomatous dermatitis who subsequently developed ulcerative colitis is described, and the characteristics of other individuals with ulcerative colitis-associated palisaded granulomatous dermatitis are reviewed. PubMed was used to search the following terms: palisaded, interstitial, granulomatous, dermatitis, ulcerative colitis, and neutrophilic. Papers were obtained and references were reviewed. Ulcerative colitis-associated palisaded granulomatous dermatitis is uncommon. Palisaded granulomatous dermatitis-associated ulcerative colitis has been reported in four individuals. The palisaded granulomatous dermatitis appeared from six years prior to diagnosis to 19 years following diagnosis of the patient’s gastrointestinal disease. In addition to individual and grouped papular lesions on the elbows, the morphology of palisaded granulomatous dermatitis can also present as indurated linear plaques overlying the metacarpophalangeal (MCP) joints and proximal fingers. 

Reactive Granulomatous Dermatitis: A Review of Palisaded Neutrophilic and Granulomatous Dermatitis, Interstitial Granulomatous Dermatitis, Interstitial Granulomatous Drug Reaction, and a Proposed Reclassification

The terms "palisaded neutrophilic and granulomatous dermatitis," "interstitial granulomatous dermatitis," and the subset "interstitial granulomatous drug reaction" are a source of confusion. There exists substantial overlap among the entities with few strict distinguishing features. We review the literature and highlight areas of distinction and overlap, and propose a streamlined diagnostic workup for patients presenting with this cutaneous reaction pattern. Because the systemic disease associations and requisite workup are similar, and the etiopathogenesis is poorly understood but likely similar among these entities, we propose the simplified unifying term "reactive granulomatous dermatitis" to encompass these entities.