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A 41-year-old fair-skinned woman requests a consultation for a rash that developed on her upper forehead more than 1 year ago and has most recently appeared on her nose as well. She denies symptoms, including itching and burning. Her medical history is positive for endometriosis and uterine fibroids and negative for connective tissue disorders and skin cancer. She denies arthritis, swollen glands, or malaise. She has experienced sunburn in the past and frequently tans indoors. Examination reveals scattered erythematous patches and plaques of the affected facial areas.
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Actinic granuloma is a rare skin condition that occurs on sun-exposed skin.1 The condition was first described by O’Brien in 1975, who associated the disorder with actinic damage.2 Some consider actinic granuloma to be a variant of granuloma annulare, whereas others consider it a distinct entity, also termed annular elastolytic giant-cell granuloma.3,4
The condition begins as flesh-colored to pink papules that coalesce into asymptomatic annular plaques with atrophic centers. The head, neck, and hands are the most commonly affected sites, and incidence is higher in females.
Differential diagnosis includes granuloma annulare, discoid lupus erythematosus, and sarcoid granuloma. Biopsy of lesions of actinic granuloma reveals dermal granulomas with multinucleated giant cells containing degenerating elastic fibers.5
Actinic granuloma is often refractory to therapy, although in some cases, spontaneous involution occurs. Case reports document clinical response to topical and intralesional steroids, isotretinoin, acitretin, chloroquine, and liquid nitrogen.6 Because actinic granulomas occur on sun-exposed skin, sun avoidance and use of a broad-spectrum high-SPF sunscreen are recommended.
Jamie Remaley, PAC, is a physician assistant with Reading Dermatology Associates in Reading, Pennsylvania.
Stephen Schleicher, MD, is an associate professor of medicine at the Commonwealth Medical College in Scranton, Pennsylvania, and an adjunct assistant professor of dermatology at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. He practices dermatology in Hazleton, Pennsylvania.
References
- Lazzarini R, Rotter A, Farias DC, Muller H. O’Brien’s actinic granuloma: an unusually extensive presentation. An Bras Dermatol. 2011;86(2):339-342.
- O’Brien JP. Actinic granuloma. An annular connective tissue disorder affecting sun and heat-damaged (elastotic) skin. Arch Dermatol. 1975;111(4);460-466.
- Ghadially R. Granuloma annulare, actinic granuloma. In: Arndt K, Lebout P, Robinson J, Wintroub B, eds. Cutaneous Medicine and Surgery: An Integrated Program in Dermatology. Philadelphia, PA: WB Saunders Co; 1996:438-443.
- Al-Hoqail IA, Al-Ghamdi AM, Martinka M, Crawford RI. Actinic granuloma is a unique and distinct entity: a comparative study with granuloma annulare. Am J Dermatopathol. 2002;24(3):209-212.
- Weedon D. Skin Pathology. 2nd ed. New York, NY: Churchill Livingstone; 2002:193-220.
- Stein JA, Fangman B, Strober B. Actinic granuloma. Dermatology Online Journal. 2007;13(1):19. Available at http://escholarship.org/uc/item/440579jf
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