Granuloma Faciale Workup

Updated: Apr 05, 2021
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
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Workup

Laboratory Studies

No laboratory abnormalities are associated with granuloma faciale.

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Procedures

Obtain an adequate skin biopsy of a representative lesion.

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Histologic Findings

The histologic findings of granuloma faciale are diagnostic. The name granuloma faciale is a misnomer, as granulomas are never present histologically. The epidermis is unaffected. A grenz zone of uninvolved dermis is located beneath the epidermis. Below the grenz zone is a dense, polymorphous inflammatory infiltrate located most often in the papillary and mid dermis. The infiltrate consists of neutrophils, lymphocytes, eosinophils, monocytes, and, occasionally, mast cells. Vasculitic changes, including perivascular inflammation with nuclear dust and vessel wall damage, are often observed. This chronic localized fibrosing leukocytoclastic vasculitis is a vasculitic reaction pattern seen in granuloma faciale and erythema elevatum diutinum. [13] Extravasated RBCs and hemosiderin deposition are found, which may contribute to the color of the lesions. Later, lesions may show considerable fibrosis around venules. See the images below.

Histologic findings in granuloma faciale. Histologic findings in granuloma faciale.
Histologic findings in granuloma faciale. Histologic findings in granuloma faciale.
Histologic findings in granuloma faciale include a Histologic findings in granuloma faciale include a normal epidermis; a grenz zone of uninvolved dermis just beneath the epidermis; and a dense, polymorphous inflammatory infiltrate located in the papillary and mid dermis. The infiltrate consists of neutrophils, lymphocytes, eosinophils, monocytes, and, occasionally, mast cells. Perivascular inflammation is also observed.

Immunophenotyping in one study documented a higher intensity of T lymphocytes than B lymphocytes, with a predominance of T CD8 lymphocytes in almost two thirds of cases, whereas other studies have tended to show the major component as T CD4 lymphocytes. [14] IgG4 was demonstrated in most, but in less than 25% of stained cells.

Direct immunofluorescence reveals immunoglobulin G (IgG), fibrin, and, occasionally, immunoglobulin M deposition at the basement membrane zone and perivascularly. Granuloma faciale in one study did not demonstrate the immunohistochemical diagnostic criteria for IgG4-related disease. [15]

Electron microscopy reveals more perivascular eosinophils than suggested by light microscopy. Charcot-Leyden crystals, the eosinophil granules, are evident within eosinophils as well as histiocytes, providing evidence of degranulation.

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