Granulomatous Facial Dermatoses
Noninfectious facial papular granulomas can be the presentation of several conditions, including granulomatous periorificial dermatitis, granulomatous rosacea, lupus miliaris disseminatus faciei, and papular sarcoidosis. Although these entities are treated distinctly from one another, they share several clinical and histological characteristics. We present 2 cases of facial papular granuloma: one patient presented with granulomatous rosacea, and the other had a presentation consistent with sarcoidosis but also demonstrated features of granulomatous periorificial dermatitis and had a protracted course of treatment. Such cases exemplify heterogeneity in the evaluation and management of this cutaneous lesion and highlight the necessity of appreciating its various potential causes.
Practice Points
- Dermatologists should be aware that noninfectious granulomatous dermatosis of the face can be caused by granulomatous periorificial dermatitis, granulomatous rosacea, lupus miliaris disseminatus faciei, and papular sarcoidosis.
- These conditions lie on a spectrum, suggested by their historical description and clinical and histological features.
- Because their clinical courses can vary considerably from patient to patient, a thorough effort should be made to differentiate these conditions.
In 1970, Mullanax and colleagues18 introduced the term granulomatous rosacea, reiterating that this entity was not tuberculous. They documented papulopustular lesions as well as telangiectasias, raising the possibility that GR does overlap with acne rosacea. More recent studies have established the current theory that GR is a histologic variant of acne rosacea because, in addition to typical granulomatous papules, its microscopic features can be seen across subtypes of acne rosacea.19,20
Various causes have been proposed for GR. Demodex mites have been reported in association with GR for nearly 30 years.19,20 In the past 10 years, molecular studies have started to define the role of metalloproteinases, UV radiation, and cutaneous peptides in the pathogenesis of acne rosacea and GR.21,22
Granulomatous rosacea typically is seen in middle-aged women.20,23 Hallmarks of rosacea, such as facial erythema, flushing, telangiectasias, pustules, and rhinophyma, are not always present in GR.5,20,23 Lesions usually are distributed around the central face, although extension to the cheeks, total facial involvement, and extrafacial lesions are possible.5,20 Histologically, perifollicular and follicular-based noncaseating granulomas with dilatation of the dermal papillary vasculature are seen.17,23 As a whole, rosacea is comparatively uncommon in dark-skinned patients; when it does occur, GR is a frequent presentation.24
First-line treatment for GR is tetracycline antibiotics.5 Unresponsive cases have been treated—largely anecdotally—with topical modalities (eg, metronidazole, steroids, immunomodulators), systemic agents (eg, dapsone, erythromycin, isotretinoin), and other therapies.5 Granulomatous rosacea tends to have a chronic course.5,23
Lupus Miliaris Disseminatus Faciei—Classic LMDF demonstrates caseating perifollicular granulomas histologically.6,17,25 Lesions tend to appear on the central face, particularly the eyelids, and can be seen extrafacially.3,6,25,26 Although LMDF originally was categorized as a tuberculid eruption, this no longer is thought to be the case.27 It is now regarded by some as a variant of GR25; however, LMDF responds poorly to tetracyclines, is more common in males, and lacks rosacealike vascular abnormalities, leading some to question this association.3,6,17 In the past 20 years, some have proposed renaming LMDF to better reflect its clinical course and to consider it independent of tuberculosis and GR.28 It usually resolves spontaneously after 1 to 3 years, leaving pitted scars.3,6
