eMedicine Specialties > Dermatology > Pediatric Diseases

Granuloma Gluteale Infantum

Marlene T Dytoc, MD, PhD, FRCPC, Associate Clinical Professor, Division of Dermatology and Cutaneous Sciences, University of Alberta, Canada
Melody Cheung-Lee, MD, Staff Physician, Department of Dermatology, University of Alberta; Alfons Krol, MD, FRCPC, Associate Professor, Department of Medicine, Division of Dermatology and Cutaneous Sciences, University of Alberta at Edmonton

Updated: Mar 27, 2009

Introduction

Background

Granuloma gluteale infantum (GGI), previously known as vegetating potassium bromide toxic dermatitis or vegetating bromidism, is a rare skin disorder of controversial etiology characterized by oval, reddish purple granulomatous nodules on the gluteal surfaces and the groin areas of infants. Lesions can also be found in intertriginous areas (eg, neck, axilla). The long axis of most lesions runs parallel to the skin lines of cleavage or maximum skin tension.

Photograph of a case of granuloma gluteale infantum.

Similar granulomas have been noted in adults confined to bed. These conditions are referred to as granuloma gluteale adultorum and diaper area granuloma of the aged.^2,3 In contrast to granuloma gluteale infantum, the adult versions are observed only in genitocrural regions and not in intertriginous areas; nodules in the adult versions are often eroded, and they do not show an arrangement parallel to the skin lines.

Photograph of a case of granuloma gluteale adultorum.

Pathophysiology

No systemic association is known.

Frequency

International

Granuloma gluteale infantum is rare; only approximately 30 cases have been reported worldwide.

Mortality/Morbidity

Discomfort, secondary infections, and scars may occur in the area of the lesions.

Sex

Males have a higher incidence of granuloma gluteale infantum than females.

Age

The condition develops in the diaper area of infants aged 4-9 months.

Clinical

History

Most infants with granuloma gluteale infantum have a history of a preceding inflammatory skin condition in an area of seborrheic or candidal dermatitis or contact with a known irritant.⁴ These conditions have been treated with a variety of topical agents, including fluorinated corticosteroids.^5,6

Physical

Lesions associated with granuloma gluteale infantum are characterized by the following⁷ :

• One to 30 lesions in affected area
• Red-purple to red-brown in color
• Nodules that are 5-40 mm in diameter
• Oval, firm-to-hard, discrete dermal nodules with smooth or slightly lichenified surfaces
• Aligned with the long axis parallel to the skin folds
• Located on the gluteal surfaces, in the groin area, and on the upper thighs, lower abdomen, or, rarely, the neck and the face
• No involvement of the inguinal folds and the gluteal cleft (presumably because diaper contact is absent)

Causes

The etiology of granuloma gluteale infantum is unclear.

• The disorder is believed to represent a unique cutaneous response to local inflammation, maceration, and secondary infection.
• Diapering-related items (eg, diapers, plastic pants, paper napkins, laundry detergents, starch, powder), halogenated corticosteroids, candidal infection, and urine and feces are possible etiologies.⁸
• Sparing of deep body folds suggests that contact occlusion is predisposing.
• Candida hyphae are detected in skin biopsy specimens obtained from some, but not all, patients. Intradermal testing to Candida albicans antigen does not elicit immediate or delayed hypersensitivity. Serum precipitates to C albicans and Candida parapsilosis are not found.
• Most patients, including infants with facial and neck lesions, have previously been treated with a topical fluorinated steroid. This observation suggests a causative role for topical fluorinated steroids in this skin disorder. Absorption of corticosteroid preparations through inflamed skin of the diaper area leads to altered dermal collagen, which, in turn, stimulates an inflammatory response.
• Urine can increase the pH of the diaper-covered area, promoting the action of fecal proteases and lipases. Together, urine and feces can irritate diapered skin, increasing its permeability and susceptibility to other irritants. Van et al reported a case related to adult urinary incontinence.⁹

Differential Diagnoses

Other Problems to Be Considered

Congenital fibromatosis (infantile myofibromatosis)
Fibrosarcoma
Foreign body granuloma

Workup

Laboratory Studies

• The following investigations may be performed to exclude other entities in the differential diagnoses for granuloma gluteale infantum:
  • Periodic acid-Schiff staining of biopsy specimens to rule out fungi
  • Potassium hydroxide slide mounts and fungal culture of biopsy specimens
  • Fite staining of biopsy specimens for acid-fast bacilli
  • Warthin-Starry stain of biopsy specimens for spirochetes
  • Polarizing microscopy of biopsy specimens for foreign bodies or crystals
  • Rapid plasma reagin test for syphilis

Procedures

• Perform a biopsy of lesions followed by hematoxylin and eosin staining of tissue sections.

Histologic Findings

Granuloma gluteale infantum exhibits the following histologic characteristics¹⁰ :

• Parakeratotic stratum corneum
• Hyperkeratosis and acanthosis of the epidermis
• Dense, superficial, and deep inflammatory infiltrate composed of lymphocytes, histiocytes, plasma cells, and a variable number of focal aggregates of neutrophils and eosinophils forming microabscesses
• Absence of foreign body giant cells
• Dilatation, elongation, and proliferation of dermal blood vessels
• Extravasation of red blood cells and deposits of hemosiderin
• No fibrous proliferation, mitosis, or spindle cell formation
• Presence of starch granules in the lesions
• Intracytoplasmic structures resembling rickettsialike bodies within dermal macrophages

Photomicrograph showing the histologic features of a case of granuloma gluteale adultorum. Granuloma gluteale infantum shares identical histologic features (original magnification X100).

Photomicrograph showing the histologic features of a case of granuloma gluteale adultorum. Granuloma gluteale infantum shares identical histologic features (original magnification X450).

Treatment

Medical Care

• Treatment is generally not required because lesions spontaneously resolve.¹¹
• Treatment of any initiating inflammatory process, with its associated maceration and secondary infection, is beneficial.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Some of the treatments used include barrier products, intralesional corticosteroids, and flurandrenolide-impregnated tape.¹²

Protectants

These agents are the treatment of choice. Protective or preventive measures include barrier products to seal the skin from exogenous factors, such as urine, feces, and other external irritants, which may predispose an individual to granuloma gluteale.

Zinc oxide (Zincofax, Ihle's Paste)

Skin protectant generally used to prevent and treat diaper rash. Use 15% ointment or 25% paste.

Dosing

Adult

Apply to affected area prn until redness disappears

Pediatric

Infants: Apply on diaper area at every diaper changing or prn until redness disappears
Children: Apply as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

For external use only; do not apply to eyes; mineral oil may facilitate removal

Corticosteroids

Intralesional administration is indicated to treat localized hypertrophic, infiltrated inflammatory lesions. Granuloma gluteale infantum, granuloma gluteale adultorum, and diaper area granuloma of the aged fit into this category of lesions. Flurandrenolide-impregnated tape, which combines a barrier with an anti-inflammatory action, has been reported to be beneficial.

Triamcinolone (Kenalog-10)

For inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Intramuscular injection may be used for widespread skin disorder or intralesional injections may be used for localized skin disorder.
Each mL of sterile, aqueous susp contains triamcinolone acetonide 10 mg. Nonmedicinal ingredients include benzyl alcohol, carboxymethylcellulose sodium, hydrochloric acid, polysorbate, sodium chloride, sodium hydroxide, and water. Suspended in sterile sodium chloride solution at a final concentration of 2.5-5 mg/mL.

Dosing

Adult

0.1-0.2 mL ID into each lesion; multiple sites separated by 1 cm or more may be injected; may repeat qwk prn

Pediatric

Administer as in adults

Interactions

Coadministration with estrogens may decrease clearance; when used with digoxin, digitalis toxicity secondary to hypokalemia may increase; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Contraindications

Documented hypersensitivity; fungal, viral, and bacterial skin infections

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Multiple complications (eg, severe infections, hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression) may occur; abrupt discontinuation of glucocorticoids may cause adrenal crisis

Flurandrenolide (Cordran tape)

Topical anti-inflammatory agent supplied as a 4 mcg/cm² topical adhesive tape. Despite possible causative role of topical corticosteroids in some cases of granuloma gluteale infantum, various hypertrophic lesions have been effectively thinned in 3 d with the use of this treatment.

Dosing

Adult

Apply to affected area after gently cleansing and drying the skin; replace after 12 h prn; allow skin to be open to air for 1 h before applying new tape

Pediatric

Apply as in adults

Interactions

Coadministration with estrogens may decrease clearance; when used with digoxin, digitalis toxicity secondary to hypokalemia may increase; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Contraindications

Documented hypersensitivity; draining lesions or flexures

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Prolonged use may cause cutaneous atrophy; can suppress growth in children and reduce host defense against surface organisms

Follow-up

Further Outpatient Care

• Care must be taken to keep the diaper area clean and to exercise precautions against further irritation.

Deterrence/Prevention

• Caregivers of patients with granuloma gluteale infantum should discontinue the use of diapers on them as much as possible.
• Contact irritants should be avoided in granuloma gluteale infantum patients.
• Protective barrier products should be instituted in granuloma gluteale infantum patients.

Complications

• Complications may include secondary bacterial or candidal infections and acquired contact hypersensitivity to topical medications.

Prognosis

• The lesions persist for 3-6 weeks, followed by spontaneous regression over 2-4 weeks.
• Residual, brown hyperpigmented macules and lax, atrophic scars are observed in some patients.

Patient Education

• Instruct the caregivers of patients to minimize potential contact irritants, which may include cloth or synthetic diapers, paper napkins, plastic pants, and halogenated corticosteroids.
• Emphasize to the caregivers of patients the importance of maintaining an intact skin barrier, gently cleansing the diaper area, and protecting the skin from additional trauma.

Miscellaneous

Medicolegal Pitfalls

• Failure to recognize other skin disorders that constitute the differential diagnoses for granuloma gluteale infantum is a pitfall.

Multimedia

Media file 1: Photograph of a case of granuloma gluteale infantum.

Media file 2: Photograph of a case of granuloma gluteale adultorum.

Media file 3: Photomicrograph showing the histologic features of a case of granuloma gluteale adultorum. Granuloma gluteale infantum shares identical histologic features (original magnification X100).

Media file 4: Photomicrograph showing the histologic features of a case of granuloma gluteale adultorum. Granuloma gluteale infantum shares identical histologic features (original magnification X450).

References

1. Tappeiner J, Pfleger L. [Granuloma gluteale infantum]. Hautarzt. Sep 1971;22(9):383-8. [Medline].

2. Fujita M, Ohno S, Danno K, Miyachi Y. Two cases of diaper area granuloma of the adult. J Dermatol. Nov 1991;18(11):671-5. [Medline].

3. Maekawa Y, Sakazaki Y, Hayashibara T. Diaper area granuloma of the aged. Arch Dermatol. Mar 1978;114(3):382-3. [Medline].

4. De Zeeuw R, Van Praag MC, Oranje AP. Granuloma gluteale infantum: a case report. Pediatr Dermatol. Mar-Apr 2000;17(2):141-3. [Medline].

5. Dytoc MT, Fiorillo L, Liao J, Krol AL. Granuloma gluteale adultorum associated with use of topical benzocaine preparations: case report and literature review. J Cutan Med Surg. May-Jun 2002;6(3):221-5. [Medline].

6. Robson KJ, Maughan JA, Purcell SD, Petersen MJ, Haefner HK, Lowe L. Erosive papulonodular dermatosis associated with topical benzocaine: a report of two cases and evidence that granuloma gluteale, pseudoverrucous papules, and Jacquet's erosive dermatitis are a disease spectrum. J Am Acad Dermatol. Nov 2006;55(5 Suppl):S74-80. [Medline].

7. Sweidan NA, Salman SM, Kibbi AG, Zaynoun ST. Skin nodules over the diaper area. Granuloma gluteale infantum. Arch Dermatol. Dec 1989;125(12):1703-4, 1706-7. [Medline].

8. Konya J, Gow E. Granuloma gluteale infantum. Australas J Dermatol. Feb 1996;37(1):57-8. [Medline].

9. Van L, Harting M, Rosen T. Jacquet erosive diaper dermatitis: a complication of adult urinary incontinence. Cutis. Jul 2008;82(1):72-4. [Medline].

10. Bluestein J, Furner BB, Phillips D. Granuloma gluteale infantum: case report and review of the literature. Pediatr Dermatol. Sep 1990;7(3):196-8. [Medline].

11. Maekawa Y, Kiyoi K, Kunitake Y. Hemilateral distribution of papular lesions on the buttock histologically resembling granuloma gluteale infantum. J Dermatol. Apr 2001;28(4):231-3. [Medline].

12. Kikuchi I, Jono M. Letter: Flurandrenolide-impregnated tape for granuloma gluteale infantum. Arch Dermatol. Apr 1976;112(4):564. [Medline].

13. Bonifazi E, Garofalo L, Lospalluti M, Scardigno A, Coviello C, Meneghini CL. Granuloma gluteale infantum with atrophic scars: clinical and histological observations in eleven cases. Clin Exp Dermatol. Jan 1981;6(1):23-9. [Medline].

14. Pierini AM. Granuloma gluteale infantum. Cutis. May 1983;31(5):489, 493. [Medline].

15. Simmons IJ. Granuloma gluteale infantum. Australas J Dermatol. Apr 1977;18(1):20-4. [Medline].

16. Thomsen K. Seborrhoeic dermatitis and napkin dermatitis. Acta Derm Venereol Suppl (Stockh). 1981;95:40-2. [Medline].

17. Walsh SS, Robson WJ. Granuloma gluteale infantum: an unusual complication of napkin dermatitis. Arch Emerg Med. Jun 1988;5(2):113-5. [Medline].

18. Wilkinson S, Goldman L. Granuloma gluteale infantum. Cutis. Dec 1981;28(6):644, 648. [Medline].

Keywords

granuloma gluteale infantum, GGI, Kaposi sarcoma-like granuloma, Kaposi sarcoma–like granuloma, granuloma intertriginosum infantum, infantile vegetating halogenosis, vegetating potassium bromide toxic dermatitis, vegetating bromidism

Contributor Information and Disclosures

Author

Marlene T Dytoc, MD, PhD, FRCPC, Associate Clinical Professor, Division of Dermatology and Cutaneous Sciences, University of Alberta, Canada
Marlene T Dytoc, MD, PhD, FRCPC is a member of the following medical societies: Alberta Medical Association, American Academy of Dermatology, and College of Physicians and Surgeons of Alberta
Disclosure: Nothing to disclose.

Coauthor(s)

Melody Cheung-Lee, MD, Staff Physician, Department of Dermatology, University of Alberta
Melody Cheung-Lee, MD is a member of the following medical societies: Alberta Medical Association, American Academy of Dermatology, Canadian Dermatology Association, and Canadian Medical Association
Disclosure: Nothing to disclose.

Alfons Krol, MD, FRCPC, Associate Professor, Department of Medicine, Division of Dermatology and Cutaneous Sciences, University of Alberta at Edmonton
Disclosure: Nothing to disclose.

Medical Editor

Evan R Farmer, MD, Professor of Dermatology, Johns Hopkins University School of Medicine, Clinical Professor of Pathology, Virginia Commonwealth University School of Medicine; Consulting Staff, Department of Dermatology, Johns Hopkins Hospital, VCU Health Services
Evan R Farmer, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Medical Association, American Society of Dermatopathology, and International Society of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Van Perry, MD, Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas Health Science Center
Van Perry, MD is a member of the following medical societies: American Academy of Dermatology and American Society for Laser Medicine and Surgery
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology
Disclosure: elsevier Royalty Other; american college of physicians Honoraria Other

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