Dermatology Practical & Conceptual

A 38-year-old Nigerian man, who had been living in Italy since 2008, presented with an annular lesion on the right temporal and frontal region that appeared two months prior to his visit. He reported a slow centrifugal enlargement of the lesion. The man complained about headache and pain radiating to the right frontal region. He was not taking any drugs. Physical examination disclosed an annular plaque of almost 10 x 8 cm in diameter (Figure 1). The margins were raised and slightly edematous, while the skin in the center was not infiltrated but dry and anaesthetic. Edema was observed around the right orbit. The supraorbital nerve was thickened and palpable (Figure 1, white arrow). Skin biopsy showed a multifocal superficial and deep granulomatous dermatitis with epithelioid granulomas (Figures 2 and 3) with perineural distribution. The granulomas were also focally “touching” the epidermis (Figure 4). Multinucleated giant cells, discrete edema within the granulomas, and dilated superficial vessels were also observed. PAS and Grocott stains were negative. Fite-Faraco stain did not show Mycobacteriae. Polymerase chain reaction (PCR) for Mycobacteriae was not performed. Enlarging plaque on the face with enlarged supraorbital nerve