Granuloma faciale effectively treated with topical pimecrolimus.

Granuloma faciale (GF) is a rare skin disorder with a chronic-relapsing course. Cutaneous lesions affect predominantly the face of middle-aged Caucasian men with characteristic reddish papules, nodules, or plaques; however, various atypical cases with unusual morphology or extra facial involvement have been reported (1-3). Despite many treatment options, both surgical and medical, GF remains therapeutically resistant and even if effective treatment is achieved, the condition often recurs. A 60-year-old woman was referred to our department with skin lesions that appeared in spring of 2008 and were resistant to topical antibiotic and cor-ticosteroid treatment. There were no other subjective complains except for aggravation from sun exposure. Clinical examination revealed four erythematous plaques localized symmetrically on both sides of the nose, on the right cheek, and between the eyebrows (Fig. 1a). A wide range of differential diagnoses were taken into consideration, including: cutaneous lupus erythematosus, sarcoidosis, polymorphic light eruption , Jessner-Kanof lymphocytic infiltration, and ery-thema fixum. Hematological and biochemical blood investigations were within normal ranges, and the serology for Treponema (T.) pallidum and Borrelia (B.) burgdorferi and the ANA test were negative. The his-tologic evaluation revealed diffuse hyperkeratosis, acanthosis, and a dense perivascular inflammatory infiltrate in the upper dermis, demarcated from the epidermis by a highly demonstrative Grenz zone. Polymorphous infiltrate of lymphocyte, neutrophils, eosinophils, and plasma cells was seen around the small-and middle-sized vessels in the papillary der-mis (Fig. 1b). The patient was treated with chloro-quine 250 mg po bid. and topical betamethasone val-erate cream for three months. The lack of significant therapeutic response led us to switch treatment to topical 1% pimecrolimus cream, applied twice daily for a period of three months. A follow-up visit after six months showed visual improvement of highly satisfying cosmetic outcome (Fig. 2). Granuloma faciale is a rare skin disease of unknown etiology. The first case was reported by Wig-ley in 1945 as " eosinophilic granuloma " , and was later named granuloma faciale by Pincus (4). A spectrum of exogenic and endogenic factors such as actinic exposure, trauma, allergy (1), an Arthus-like reaction, or light irradiation (5) have been suspected to trigger the disease. GF has been typically described in middle aged white men, though it can occur in any gender , race, or age group. Our case features GF changes in a middle-aged woman, which is a relatively rare phenomenon. GF clinical presentation is characterized with variously colored papules, nodules, or plaques, commonly …