Granuloma Gluteale Infantum

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. The lesions typically are self-limited.

Photograph of a case of granuloma gluteale infantum.

A similar eruption may have been described in 1891, and, in 1962, as vegetating bromidism due to the application of bromide ointment. In 1971, Tappeiner and Pfleger, from Germany, first reported 6 cases of granuloma gluteale infantum.[1] In subsequent years, similar episodes were reported in other parts of Europe, Japan, and the United States.

Similar granulomas have been noted in adults confined to bed and women who overuse vaginal preparations such as Vagisil. These conditions are referred to as pseudoverrucous nodules of the vulva, 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.[4, 5]

Photograph of a case of granuloma gluteale adultorum.

Advances in absorbent diaper technology using synthetic materials have significantly reduced diaper-associated inflammatory skin conditions in recent decades. Also see Pediatrics, Diaper Rash and Diaper Dermatitis.

No systemic association is known.

Granuloma gluteale infantum is the result of chronic maceration. Diapering-related items (eg, diapers, plastic pants, paper napkins, laundry detergents, starch, powder), halogenated corticosteroids, candidal infection, and urine and feces are possible contributing factors.[6, 7, 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.[4, 5, 9]

Frequency

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

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.

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.

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.

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.[10, 11] These conditions have been treated with a variety of topical agents, including fluorinated corticosteroids.[12, 13]

Lesions associated with granuloma gluteale infantum are characterized by the following[14] :

• 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)

Discomfort, secondary infections, and scars may occur in the area of the lesions. Complications may include secondary bacterial or candidal infections and acquired contact hypersensitivity to topical medications.

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

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

Granuloma gluteale infantum exhibits the following histologic characteristics[15] :

• 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 is generally not required because lesions spontaneously resolve.[16]  Ramos Pinheiro et. al. reported the use of calneurin inhibitor pimecrolimus 0.1% cream with resolution.[8] Treatment of any initiating inflammatory process, with its associated maceration and secondary infection, is beneficial.

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.

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

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.[17]

Class Summary

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 topical (Aveeno Baby Organic Harvest Diaper Rash Cream, Desitin, Desitin Creamy)

Zinc oxide is a skin protectant generally used to prevent and treat diaper rash. Use 15% ointment or 25% paste.

Class Summary

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)

Triamcinolone is for inflammatory dermatosis responsive to steroids; it decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. Intramuscular injections may be used for widespread skin disorders or intralesional injections may be used for localized skin disorders.

Each mL of sterile, aqueous suspension contains triamcinolone acetonide 10 mg. Nonmedicinal ingredients include benzyl alcohol, carboxymethylcellulose sodium, hydrochloric acid, polysorbate, sodium chloride, sodium hydroxide, and water. It is suspended in sterile sodium chloride solution at a final concentration of 2.5-5 mg/mL.

Flurandrenolide (Cordran tape)

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