Treatment of Annular Elastolytic Giant Cell Granuloma With Topical Tretinoin

July 2017 | Volume 16 | Issue 7 | Case Report | 699 | Copyright © 2017

Aubrey Wagenseller MD, Cecilia Larocca MD, and Neelam A. Vashi MD

Boston University School of Medicine, Boston, MA

Abstract

Annular elastolytic giant cell granuloma, also known as actinic granuloma, is a rare skin condition with a chronic course that is often resistant to treatment. Literature is sparse, and only a handful of case reports are available to guide treatment decisions. Typical first line treatment options include topical and intralesional steroids, topical pimecrolimus, and cryotherapy. Resistant cases have been treated with cyclosporine, systemic steroids, antimalarials, and oral retinoids. In particular, acitretin and isotretinoin have shown success in three cases. However, these medications can have side effects and require frequent lab monitoring. We present a case of a 47-year-old woman with bilateral forearm lesions consistent with annular elastolytic giant cell granuloma who was successfully treated with topical tretinoin.

J Drugs Dermatol. 2017;16(7):699-700.

Purchase Original Article

Purchase a single fully formatted PDF of the original manuscript as it was published in the JDD.

Download the original manuscript as it was published in the JDD.

Contact a member of the JDD Sales Team to request a quote or purchase bulk reprints, e-prints or international translation requests.

To get access to JDD's full-text articles and archives, upgrade here.

Save an unformatted copy of this article for on-screen viewing.

Print the full-text of article as it appears on the JDD site.

→ proceed | ↑ close

INTRODUCTION

Annular elastolytic giant cell granuloma (AEGCG), also known as actinic granuloma, is a rare granulomatous skin disorder that usually develops in areas of actinic elastosis.1 First described in 1975 by O’Brien et al, lesions are characterized by asymptomatic annular plaques with elevated and erythematous borders and slightly atrophic and hypopigmented centers.2 Lesions are predominantly located on the head and neck and other chronically sun-exposed areas.2,3 Both proper classification (either as a distinct entity or variant of granuloma annulare) and etiology are widely debated. The leading theory implicates a cell-mediated immunologic response to a weak antigen on elastic fibers that are likely altered due to photodamage.3-5While a few cases of spontaneous resolution have been reported, those that are chronic are treated by a wide range of therapies with variable success.4 Three case reports have shown efficacy of acitretin and isotretinoin.1,6,7 Here, we present a case of annular elastolytic giant cell granuloma responding to topical tretinoin therapy.

CASE REPORT

A 47-year-old healthy Hispanic woman presented to our dermatology clinic in February 2013 with a history of well-demarcated, firm, erythematous annular plaques with central clearing on the bilateral forearms and dorsal aspects of her hands (Figure 1A). Lesions were somewhat pruritic. Biopsy of a representative lesion showed a mild to moderate superficial palisaded lymphohistiocytic infiltrate with admixed multinucleate giant cells, several of which exhibited elastophagocytosis. The specimen was noted to lack discernible necrobiosis and increased mucin, arguing against granuloma annulare. On the basis of these histological findings and the clinical presentation, the patient was diagnosed with annular elastolytic giant cell granuloma. Initial treatment with three rounds of cryotherapy spaced one month apart and two months of twice daily topical clobetasol 0.5% ointment proved ineffective. Given her treatment-resistant lesions and desire for complete resolution, we decided to start isotretinoin; however, she was unable to obtain the medication due to inadequate insurance coverage. A trial of topical tretinoin was subsequently attempted. The patient used topical tretinoin 0.025% cream every other day for two months followed by daily usage for one month. She reported significant improvement with flattening of lesions after approximately six weeks of every-other-day usage with a sustained response at eight months follow-up (Figure 1B). She noted only mild dryness as a side effect.

DISCUSSION

Annular elastolytic giant cell granuloma (AEGCG) typically runs a chronic and persistent course. While some lesions may spontaneously resolve in a few months to years, most have a poor and often inconsistent response to a myriad of treatments with disparate mechanisms of action.4 Unsurprisingly, there are no randomized controlled trials to guide treatment decisions for this rare condition and thus, there is no standard therapy. A trial of cryotherapy or topical or intra-lesional steroids is often attempted first, although responses vary.8-10 In addition, patients are counseled regarding sun protection and sun avoidance to prevent further lesions.11 Other case reports have documented responses to retinoid-PUVA (RePUVA)12 and a combination of oral tranilast with topical pimecrolimus.13 For resistant cases, cyclosporine for eight weeks,14 systemic steroids,15 and antimalarial drugs, including chloroquine4 and hydroxychloroquine,16 have also shown success in limited case reports. However,

↑ back to top


  • 1
  • 2

Related Articles