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Christie T. Ammirati, MD; George J. Hruza, MD
Division of Dermatology, Washington University School of Medicine, St Louis, Mo

Arch Dermatol. 1999;135:903-905.

REPORT OF A CASE
A 41-year-old white man with a long history of acne rosacea was referred for evaluation of a persistent erythematous lesion on his nose. The lesion had been present for 2 years and had proved resistant to topical and oral antibiotic therapy. Examination of the patient's face revealed malar erythema, scattered acneiform papules, and an absence of comedones, consistent with mild acne rosacea. On the dorsum of the nose, there was a discrete 2-cm, reddish-brown, indurated plaque with prominent telangiectasias (Figure 1). The clinical differential diagnosis included granuloma faciale, sarcoidosis, and discoid lupus erythematosus. Histopathologic findings were consistent with granuloma faciale and revealed a mixed infiltrate in the papillary and reticular dermis composed of neutrophils, eosinophils, plasma cells, lymphocytes, and monocytes. There was an overlying Grenz zone noted, as well as associated leukocytoclastic vasculitis.

View larger version (116K): [in this window] [in a new window] Figure 1. Pretreatment appearance of granuloma faciale on the dorsum of the nose.

THERAPEUTIC CHALLENGE

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Granuloma faciale is a benign granulomatous process that is frequently resistant to therapy. Multiple medical and surgical modalities have been suggested, but none have been consistently efficacious. The prominent facial location of this lesion required that the posttreatment residual be cosmetically acceptable as well. Our challenge was to treat this patient's persistent and disfiguring lesion effectively, yet minimize the risk for scarring, dyspigmentation, or systemic adverse effects.

SOLUTION

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The 585-nm pulsed dye laser is the treatment of choice for a variety of vascular lesions.¹ It uses the concept of selective photothermolysis to target the oxyhemoglobin within blood vessels, while minimizing collateral damage. The reddish-brown color and prominent telangiectasias of granuloma faciale suggested that it might be amenable to treatment with this laser.

The lesion underwent 2 treatments, spaced 2 months apart, with a flashlamp-pumped pulsed dye laser (SPTL-1b; Candela Laser Corp, Wayland, Mass). A wavelength emission of 585 nm and a pulse duration of 450 microseconds were used. The treatments were performed with 5 mm minimally overlapping spots at 8.0 J/cm² for the first treatment and 8.5 J/cm² for the second treatment. No anesthesia was needed and there was no significant postoperative discomfort. Follow-up 2 months after the second pulsed dye laser treatment (Figure 2) and at 6 years (Figure 3) confirmed clinical eradication of the lesion without scarring or pigmentary change.

View larger version (96K): [in this window] [in a new window] Figure 2. Clinical resolution 2 months after the second 585-nm pulsed dye laser treatment.

View larger version (96K): [in this window] [in a new window] Figure 3. No clinical recurrence of granuloma faciale at 6-year follow-up. Note interim progression of underlying rhinophyma.

COMMENT

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The term granuloma faciale was first coined by Pinkus² in 1952. Formerly, this rare cutaneous disorder had been called eosinophilic granuloma of the skin. While granuloma faciale has been reported in children and adult women,³ the typical patient is a middle-aged white man. Clinically, granuloma faciale presents as a reddish-brown or violaceous plaque on the face, often with follicular accentuation and superficial telangiectasias. The sites of predilection are the sides (30%) and tip (7%) of the nose, preauricular area (22%), cheeks (22%), forehead (15%), tip of the nose (7%), and helix of the ear (4%).⁴ Extrafacial granuloma faciale has also been reported but is rare.^5-6 The clinical differential diagnosis includes sarcoidosis, discoid lupus erythematosus, lymphocytic infiltrate of Jessner, polymorphous light eruption, rosacea, lymphoma cuffs, histiocytosis X, erythema elevatum diutinum, infectious granuloma, and basal cell carcinoma.^7-10 Histologically, granuloma faciale displays a dense polymorphous infiltrate of the upper two thirds of the dermis. Eosinophils may be present but are not essential for diagnosis. There is sparing of the epidermis, with a notable Grenz zone and a leukocytoclastic vasculitis in the upper dermis.¹¹

Response to therapy is variable. Medical modalities that have been proposed include colchicine,¹² dapsone,^13-16 antimalarials,^{7, 17} gold injections,⁴ isoniazid,^{4, 12} clofazimine,^18-19 topical psoralen with UV-A,²⁰ and corticosteroids in topical,^{14, 17} intralesional,^{3, 7, 17, 21} and systemic forms.^{4, 7, 12} None of them have been consistently effective, and a large proportion of them have substantial well-known adverse effects, such as hemorrhagic gastroenteritis, blood dyscrasias, oculotoxicity, nephrotoxicity, peripheral neuropathy, skin discoloration, actinic damage, atrophy, and adrenal suppression.²² Surgical treatments have included wide excision,^{2, 20} cryotherapy,^23-25 radiation,^{4, 7, 21} electrodesiccation with and without curettage,⁴ and dermabrasion.^{4, 26} These modalities have been used with varying degrees of success, and all pose a significant risk for permanent pigmentary changes and scarring.

One of the first lasers used to treat granuloma faciale was the carbon dioxide laser. This infrared laser vaporizes tissues in a nonselective manner and has the associated risks of hypopigmentation and scarring. Wheeland et al²⁷ reported the successful treatment of granuloma faciale with this laser. Other investigators, however, were unable to reproduce their results. In a side-by-side comparison of electrosurgery, carbon dioxide laser, and dermabrasion, Dinehart et al²⁸ noted a recurrence in all 3 sites at 1 year. Also, the argon laser was thought to be a promising treatment for granuloma faciale. Apfelberg et al¹² reported total and complete resolution of granuloma faciale with the argon laser, but their treatment was complicated by a white collagenous scar.

The pulsed dye laser, with a wavelength of 585 nm and a pulse duration of 450 microseconds, is highly effective for the selective destruction of vascular lesions, especially pediatric port-wine stains,^29-30 superficial hemangiomas,³⁰ and telangiectasias.³¹ Its unsurpassed safety profile and efficacy are attributable to its ability to achieve selective photothermolysis.^32-34 The 585-nm pulsed dye laser emits energy that is strongly absorbed by oxyhemoglobin, and its 450-microsecond pulse duration is shorter than the 1- to 5-microsecond thermal relaxation time of blood vessels 50 to 100 µm in diameter.³⁵

In the case presented herein, the lesion had a distinct reddish-brown hue and prominent telangiectasias, which suggested that it might respond to the 585-nm pulsed dye laser. The result was persistent clinical eradication of the lesion without evidence of scarring or pigment change at the 6-year follow-up. Since the time that our patient was treated, the short-pulsed or scanned carbon dioxide and erbium:YAG lasers for skin resurfacing have been added to the surgeon's armamentarium. It is our belief that these lasers, with their precise depth control, may also provide safe and effective treatment options for granuloma faciale. Further studies will be needed to confirm this.

In summary, we report a case of granuloma faciale on the nose of a white man that was successfully treated by the 585-nm pulsed dye laser. Because of the noninvasive nature of this laser, there was minimal postoperative discomfort and no complicated wound care. Persistent clinical eradication for 6 years was achieved without scarring, permanent pigmentary alteration, or systemic morbidity. The 585-nm pulsed dye laser provided safe and effective treatment for this often-resistant lesion and warrants further investigation on a larger scale.

REFERENCES

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1. Ross BS, Levine V J, Ashinoff R. Laser treatment of acquired vascular lesions. Dermatol Clin. 1997;15:385-396. FULL TEXT | ISI | PUBMED 2. Pinkus H. Granuloma faciale. Dermatologica. 1952;105-85-99. 3. Pedace FJ, Perry HO. Granuloma faciale: a clinical and histopathologic review. Arch Dermatol. 1966;94:387-396. FREE FULL TEXT 4. Johnson WC, Higdon RS, Helwig EB. Granuloma faciale. Arch Dermatol. 1959;79:42-52. FREE FULL TEXT 5. Sears JK, Gitter DG, Stone MS. Extrafacial granuloma faciale. Arch Dermatol. 1991;127:742-743. FREE FULL TEXT 6. Rusin L J, Dubin HV, Taylor WB. Disseminated granuloma faciale. Arch Dermatol. 1976;121:1575-1577. 7. Black Cl. Granuloma faciale. Cutis. 1977;20:66-68. ISI | PUBMED 8. Horn T. Long-standing erythematous facial plaques: granuloma faciale. Arch Dermatol. 1985;121:1553-1554, 1556-1557. FREE FULL TEXT 9. Phillips DK, Hymes SR. Recurrent facial plaques following full-thickness grafting: granuloma faciale. Arch Dermatol. 1992;130:1433-1434, 1436-1437. 10. Kolbusz RV, Pearson RW. Solitary plaque on the cheek: granuloma faciale. Arch Dermatol. 1993;129:634-635, 637. FULL TEXT | PUBMED 11. Mehregan A, Hashimoto K, Mehregan D. Pinkus' Guide to Dermatohistopathology. 6th ed. East Norwalk, Conn: Appleton & Lange; 1995:239-240. 12. Apfelberg DB, Druker D, Maser M, Lash H, Spence B Jr, Deneau D. Granuloma faciale: treatment with the argon laser. Arch Dermatol. 1983;119:573-576. FREE FULL TEXT 13. Anderson CR. Dapsone in granuloma faciale. Lancet. 1975;1:642. 14. Goldner R, Sina B. Granuloma faciale: the role of dapsone and prior irradiation on the cause of the disease. Cutis. 1984;33:478-480. ISI | PUBMED 15. Guill MA, Aton JK. Facial granuloma responsive to dapsone therapy. Arch Dermatol. 1982;118:332-335. FREE FULL TEXT 16. van de Kerkhof PCM. On the efficacy of dapsone in granuloma faciale. Acta Derm Venereol. 1994;74:61-62. ISI | PUBMED 17. Brown M. Granuloma faciale. Arch Dermatol. 1974;110:477-478. FULL TEXT | ISI | PUBMED 18. Jacyk WK. Facial granuloma in a patient treated with clofazimine. Arch Dermatol. 1981;117:597-598. FREE FULL TEXT 19. Wollina U, Karte K, Geyer A, Stuhlert A, Bocker T. Clofazimine in inflammatory facial dermatosis: granuloma faciale and lipogranulomatosis subcutanea (Rothman-Makai). Acta Derm Venereol. 1996;76:77-79. ISI | PUBMED 20. Hudson LD. Granuloma faciale: treatment with topical psoralen and UVA. J Am Acad Dermatol. 1983;8:559. ISI | PUBMED 21. Arundell FD, Burdick KH. Granuloma faciale treated with intradermal dexamethasone. Arch Dermatol. 1960;82:437-441. FREE FULL TEXT 22. Wolverton SE, Wilkin JK. Systemic Drugs for Skin Diseases. Philadelphia, Pa: WB Saunders Co;1991. 23. Graham GF, Stewart R. Cryosurgery for unusual cutaneous neoplasms. J Dermatol Surg Oncol. 1977;3:437-442. PUBMED 24. Franks, AG. Diagnosis: facial granuloma with eosinophils. Arch Dermatol. 1960;82:1019-1020. ISI 25. Zacarain SA. Cryosurgery effective for granuloma faciale. J Dermatol Surg Oncol. 1985;11:11-13. ISI | PUBMED 26. Bergfeld WF, Scholes HT, Roenigk HH. Granuloma faciale: treatment by dermabrasion: report of a case. Clev Clin Q. 1970;37:215-218. 27. Wheeland RG, Ashley JR, Smith D, Ellis D, Wheeland D. Carbon dioxide laser treatment of granuloma faciale. J Dermatol Surg Oncol. 1984;10:730-732. ISI | PUBMED 28. Dinehart SM, Gross DJ, Davis CM, Herzberg AJ. Granuloma faciale: comparison of different treatment modalities. Arch Otolaryngol Head Neck Surg. 1990;116:849-851. FREE FULL TEXT 29. Levine V J, Geronemus RG. Adverse effects associated with the 577 and 585 nanometer pulsed dye laser in the treatment of cutaneous vascular lesions: a study of 500 patients. J Am Acad Dermatol. 1995;32:613-617. FULL TEXT | ISI | PUBMED 30. Garden JM, Geronemus RG. Dermatologic laser surgery. J Dermatol Surg Oncol. 1990;16:156-168. ISI | PUBMED 31. Polla LL, Tan OT, Garden JM, Parrish JA. Tunable pulsed dye laser for the treatment of benign cutaneous vascular ectasia. Dermatologica. 1987;174:11-17. ISI | PUBMED 32. Tan OT, Sherwood K, Gilchrest BA. Treatment of children with port wine stains using the flashlamp-pulsed dye laser. N Engl J Med. 1989;320:416-421. ABSTRACT 33. Badow RJ, Walker NPJ, Markey AC. Treatment of proliferative hemangioma with the 585 nm pulsed dye laser. J Dermatol Surg Oncol. 1996;134:700-704. 34. Geronemus RG. Pulsed dye laser treatment of vascular lesions in children. J Dermatol Surg Oncol. 1993;19:303-309. ISI | PUBMED 35. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science. 1983;220:524-527. FREE FULL TEXT

SECTION EDITOR: GEORGE J. HRUZA, MD; ASSISTANT SECTION EDITORS: LYNN A. CORNELIUS, MD; JON STARR, MD

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