In the Issue…
Skin complexion and pigmentary disorders in facial skin of 1204 women in 4 Indian cities Evaluation of key histologic variables in skin biopsies of patients of borderline leprosy with type
1 lepra reaction
Evaluation of an ablative and non-ablative laser procedure in the treatment of striae distensae Clinicopathologic assessment of Candida colonization of oral leukoplakia
Intralesional radiofrequency ablation for nodular angiolymphoid hyperplasia on forehead: A minimally invasive approach
Indian Journal of
Dermatology, Venereology & Leprology
An IADVL PublicationSeptember-October
2014
Issue 5
Volume 80
www.ijdvl.com
Indian Journal of Dermatology , Venereology & Leprology •
Letters to the Editor
475 Indian Journal of Dermatology, Venereology, and Leprology | September-October 2014 | Vol 80 | Issue 5
Address for correspondence: Dr. Rashmi Kumari, Department of Dermatology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry ‑ 605 006, India. E‑mail: rashmi.sreerag@gmail.com REFERENCES
1. Hoffmann E, Zurhelle, E. Über einen Naevus lipomatodes cutaneous superficialis der linken Glutaalgegend. Arch Dermatol Syphilol 1921;130:327‑33.
2. Jones EW, Marks R, Pongsehirun D. Naevus superficialis lipomatosus: A clinicopathological report of twenty cases. Br J Dermatol 1975;93:121‑33.
3. Dotz W, Prioleau PG. Nevus lipomatosus cutaneous superficialis. A light and electron microscopic study. Arch Dermatol 1984;120:376‑9.
4. Nakashima K, Yoshida Y, Yamamoto O. Nevus lipomatosus cutaneous superficialis of the vulva. Eur J Dermatol 2010;20:859‑60.
5. Hattori R, Kubo T, Yano K, Tanemura A, Yamaguchi Y, Itami S,
et al. Nevus lipomatosus cutaneous superficialis of the clitoris.
Dermatol Surg 2003;29:1071‑2.
6. de Paula Mesquita T, de Almeida HL Jr, de Paula Mesquita MC. Histologic resolution of naevus lipomatosus superficialis with intralesional phosphatidylcholine. J Eur Acad Dermatol Venereol 2009;23:714‑5.
7. Kim HS, Park YM, Kim HO, Lee JY. Intralesional phosphatidylcholine and sodium deoxycholate: A possible treatment option for nevus lipomatosus superficialis. Pediatr Dermatol 2012;29:119‑21.
8. Rotunda AM, Suzuki H, Moy RL, Kolodney MS. Detergent effects of sodium deoxycholate are a major feature of an injectable phosphatidylcholine formulation used for localized fat dissolution. Dermatol Surg 2004;30:1001‑8.
9. Salti G, Ghersetich I, Tantussi F, Bovani B, Lotti T. Phosphatidylcholine and sodium deoxycholate in the treatment of localized fat: A double‑blind, randomized study. Dermatol Surg 2008;34:60‑6.
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*****
Annular elastolytic giant cell
granuloma treated with topical
pimecrolimus
Sir,
Annular elastolytic giant cell granuloma is a rare granulomatous skin disease characterized by loss of elastic fibers along with elastophagocytosis by multinucleated giant cells. It clinically presents as small
papules which evolve into annular and serpiginous plaques that have slightly raised borders. The centre of the plaque may show hypopigmentation or atrophic changes or both. These are found most commonly over the sun‑exposed areas but can be seen over sun‑protected areas as well. The other clinical variants include a pure papular form with absence of centrifugal annular lesions and those with reticular, brown to livid, partly atrophic skin lesions.[1,2] The etiopathogenesis of
this condition is not clear. It is thought that ultraviolet radiation, heat or other unknown factors transform the antigenicity of the elastic fibers thus inducing a cellular immune response.[3] The condition usually follows
a chronic course, although cases of spontaneous remission have been described. The treatment remains a challenge and several therapeutic modalities have been tried. These include topical, intralesional and systemic steroids, clofazimine, cryotherapy, dapsone, cyclosporine A, methotrexate, psoralen plus ultraviolet A therapy, narrowband ultraviolet B therapy, retinoids, fumaric acid esters, antimalarials, topical calcineurin inhibitors and tranilast alone or in combination with pimecrolimus.[1‑5] We report a case of annular elastolytic
giant cell granuloma successfully treated with topical pimecrolimus.
A 63‑year‑old man with complained of two gradually increasing mildly itchy, annular plaques over the right parietal and occipital scalp for 4 months. The lesion over the parietal scalp appeared first and measured 11 cm in diameter while the other appeared a month later and was 4 cm wide. On examination, these annular plaques had slightly raised, brownish, serpiginous borders and a hypopigmented atrophic center [Figure 1a and b]. There were no other skin or mucosal lesions. Skin biopsy revealed a non‑palisading granulomatous infiltrate in the upper dermis with many multinucleated giant cells and signs of elastophagocytosis [Figure 2a and b]. Van Gieson special staining revealed loss of elastic fibers in the areas of granulomatous infiltrate [Figure 2c]. On the basis of clinical and histopathological data, a diagnosis of annular elastolytic giant cell granuloma was made. The patient was treated with pimecrolimus 1% cream twice daily. The lesions resolved with residual atrophy after 3 weeks after which we stopped therapy [Figure 1c and d]. There was no recurrence at follow up two months later.
Letters to the Editor
Indian Journal of Dermatology, Venereology, and Leprology | September-October 2014 | Vol 80 | Issue 5 476
Figure 1: Sharply demarcated annular plaques with slightly raised, brownish, serpiginous borders and hypopigmented, atrophic center localized over the, (a) occipital and, (b) right parietal areas of the scalp at the first visit and, (c and d) after 3 weeks of therapy with topical pimecrolimus
d c
b a
Figure 2: (a) Non palisading granulomatous infiltrate composed predominantly of multinucleated giant cells located in upper reticular dermis (H and E, ×40), (b) magnified view of multinucleated giant cells with signs of elastophagocytosis (H and E, ×200), (c) loss of elastic fibers in the areas of granulomatous infiltrates (Van Gieson staining, ×40)
c
b a
prolonged treatment with topical steroids is not always effective and leads to cutaneous atrophy, a finding often already present in this condition.[1] Other topical therapies
include the calcineurin inhibitors tacrolimus and pimecrolimus.[1,3] However, the efficacy of pimecrolimus
has been demonstrated only in association with oral tranilast, an anti‑allergic drug which may directly affect the activity of cells of the monocyte macrophage line.[3]
The mechanism by which calcineurin inhibitors work in this condition is not clear. Several hypotheses have been proposed which include reduction in the number of lesional CD4+ T‑cells, decreased production of cytokines
such as interleukin‑4, interleukin‑13, macrophage colony stimulating factor and γ‑interferon, and inhibition of the cellular immune reaction inducing granulomas around elastic fibers.[1,3]
Although we cannot exclude a spontaneous regression of disease, the significant clinical improvement observed in our case shortly after starting topical pimecrolimus suggests the efficacy of this drug and indicates its possible use as monotherapy. Further studies and reports are needed to confirm these assumptions.
Enzo Errichetti, Giuseppe Stinco,
Claudio Avellini
1, Pasquale Patrone
Department of Experimental and Clinical Medicine, Institute of
Dermatology, University of Udine, 1Department of Laboratory
Medicine, Institute of Pathological Anatomy, University Hospital of Santa Maria della Misericordia, Udine, Italy
Address for correspondence: Dr. Giuseppe Stinco, Department of Experimental and Clinical Medicine, Institute of Dermatology, University of Udine, Ospedale “San Michele”, Piazza Rodolone 1, 33013 Gemona del Friuli, Udine, Italy. E‑mail: giuseppe.stinco@uniud.it REFERENCES
1. Rongioletti F, Baldari M, Burlando M, Parodi A. Papular elastolytic giant cell granuloma: Report of a case associated with monoclonal gammopathy and responsive to topical tacrolimus. Clin Exp Dermatol 2010;35:145‑8.
2. Can B, Kavala M, Türkoğlu Z, Zindancı I, Topaloğlu F, Zemheri E. Successful treatment of annular elastolytic giant cell granuloma with hydroxychloroquine. Int J Dermatol 2013;52:509‑11.
3. Lee HW, Lee MW, Choi JH, Moon KC, Koh JK. Annular elastolytic giant cell granuloma in an infant: Improvement after treatment with oral tranilast and topical pimecrolimus. J Am Acad Dermatol 2005;535 Suppl 1:S244‑6.
4. Espiñeira‑Carmona MJ, Arias‑Santiago S, Aneiros‑Fernández J, Fernández‑Pugnaire MA, Naranjo‑Sintes R, Aneiros‑Cachaza J. Annular erythematous papules in the neckline. Dermatol Online J 2011;17:7.
5. Babuna G, Buyukbabani N, Yazganoglu KD, Baykal C. Effective
treatment with hydroxychloroquine in a case of annular elastolytic giant cell granuloma. Indian J Dermatol Venereol Leprol 2011;77:110‑1.
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DOI:
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