Intralesional Steroids for the Management of Periorificial Granulomatous Dermatitis

September 2019 | Volume 18 | Issue 9 | Features | 955 | Copyright © September 2019

Stephanie von Csiky-Sessoms, Ellen Marmur MD

Marmur Medical, New York, NY

Abstract
A42-year-old male with skin type I and a history of rosacea and eczema presented with crusting, erythema, and pustules distributed on the left oral commissure. Angular cheilitis was diagnosed and regular petrolatum use recommended until resolution of the lesion. Eight days later, with no improvement in symptoms, fungal and bacterial cultures were performed which resulted in the growth of cutibacterium acnes, a variant of p. acnes.
A 42-year-old male with skin type I and a history of rosacea and eczema presented with crusting, erythema, and pustules distributed on the left oral commissure. Angular cheilitis was diagnosed and regular petrolatum use recommended until resolution of the lesion. Eight days later, with no improvement in symptoms, fungal and bacterial cultures were performed which resulted in the growth of cutibacterium acnes, a variant of p. acnes. Blue light therapy with a 417nm LED source for 20 minutes every week for three weeks led to moderate improvement in symptoms and decreased erythema of the lesion. A 3mm punch biopsy of the left oral commissure was performed and intralesional triamcinolone injected (0.2 mL of 5.0mg/mL for a total dose of 1 mg of triamcinolone). The patient reported marked improvement of the perioral lesions within one week of the injection. The pathology was found to be consistent with granulomatous periorificial dermatitis (GPD), a benign condition. Three months post biopsy, the patient denied any worsening or flare of the lesion.

This condition most often affects pre-pubescent children. Histologically, granulomatous periorificial dermatitis and granulomatous rosacea can be indistinguishable. It has been hypothesized that the two diseases are simply variations of the same disease process that lie along a spectrum.1 Erythema, telangiectasias, pustules and edema are more commonly found in granulomatous rosacea while granulomatous dermatitis typically presents with small red or brown clustered papules.2,3 Treatment of these granulomatous lesions, particularly granulomatous periorificial dermatitis, is controversial. The pathogenesis of GPD is believed to be closely linked to topical steroid use, and it has been reported that the use of steroids exacerbates GPD lesions.4 However, our patient experienced marked improvement in the perioral lesion in response to intralesional steroid injections with resolution of pustules and a decrease in erythema and induration within three days of treatment. While steroids may or may not play a role in the pathogenesis of GPD, this case suggests that intralesional steroids should be considered for patients suffering from localized GPD or granulomatous rosacea refractory to other therapies.



Disclosure:
E. Marmur has financial relationships with Revance, Galderma, Auergan, Merz, and MM Skincare. S. von Csiky-Sessoms has no conflicts.

References:
1. Savin JA, Alexander S, Marks R. A rosacea-like eruption of children. Br J Dermatol. 1972;87(5):425-29 doi: 10.1111/j.1365-2133.1972.tb01589.x

2. Urbatsch AJ, Frieden I, Williams ML, Elewski BE, Mancini AJ, Paller AS. extrafacial and generalized granulomatous periorificial dermatitis. Arch Dermatol. 2002;138(10):1354-58 doi: 10.1001/archderm.138.10.1354

3. Lucas CR, Korman NJ, Gilliam AC. Granulomatous periorificial dermatitis: a variant of granulomatous rosacea in children? J Cutaneous Med Surg. 2009;13(2):115-18 doi: 10.2310/7750.2008.07088

4. Zalaudek I. Childhood granulomatous periorificial dermatitis: a controversial disease. J der Deutschen Dermatologischen Gesellschaft;3(4):252-55