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Idiopathic facial aseptic granuloma — Have we met?

DII small banner By Warren R. Heymann, MD
July 20, 2017

I’m racking my brain wondering if I have ever seen a case of idiopathic facial aseptic granuloma (IFAG) — I know that I never made the diagnosis because I had never heard the term until I read the first reference. I surmise that I have seen and misdiagnosed it as an inflamed epidermoid cyst or acne. I am delighted to be able to place a name on such a lesion that may present so dramatically.
Satta et al reported the case of a 1-year-old boy who developed multiple asymptomatic firm reddish nodules of the frontal, zygomatic, palpebral area, and chin. There was some drainage, but all cultures were negative. A biopsy demonstrated a granulomatous infiltrate with giant cells. The lesions were present for 4 months and were unresponsive to topical and systemic antibiotics. Over the following year “the lesions gradually and spontaneously healed without sequelae.” (1)

In a review of 30 children with IFAG (17 boys and 13 girls, mean age 3.8 years), lesions presented as a solitary painless facial nodule on the cheek. Ultrasound studies revealed a solid well-demarcated hypoechoic lesion without calcium deposits. Routine bacterial cultures were negative in 70% of cases;  cultures for mycobacteria and cat scratch disease serologies were also negative. Histological examination, performed in five cases, showed a chronic dermal lymphohistiocytic granuloma with numerous foreign body-type giant cells. Antibiotic therapy was ineffective; the lesion healed spontaneously with a mean duration of 11 months (2). More recently, it has been demonstrated that patients may have multiple lesions, as in Satta’s case (1), and may also be associated with chalazions (3).
The differential diagnosis for IFAG includes infantile acne, pediatric rosacea, insect bites, epidermoid cysts, dermoid cysts, pliomatricomas, xanthogranulomas, vascular malformations, rhabdomyosarcoma, lymphoma cutis, furunculosis, and nontuberculous mycobacterial infections (1, 4). The distribution, lack of comedones, clinical and histologic appearance confirm the diagnosis.

The pathogenesis of IFAG is unknown, although increasingly it is believed to be a variant of granulomatous rosacea. Baroni et al opine that although IFAG is not included among the criteria for childhood rosacea, its association with relapsing chalazions, facial telangiectasias, and conjunctivitis, and the frequent localization to the eyelids suggest that it could belong to the rosacea spectrum (5) Other theories have suggested that minor trauma, embryonic rests, or insect bites could be at play (6).

Therapeutically, even though systemic antibiotics, anti-rosacea agents (notably metronidazole) and surgery have been utilized, it is the tendency for spontaneous resolution that allows expectant observation to possibly be the best approach. If I ever secure this diagnosis and watch the lesions improve, as anticipated, IFAG (I Fully Acknowledge Gratitude) to my colleagues for bringing this entity to my attention.

1. Satta R, et al. Idiopathic facial aseptic granuloma: Case report and review of the literature. Int J Dermatol 2016; 55: 1381-7.
2. Boralevi F, et al. Idiopathic facial aseptic granuloma: a multicenter prospective study of 30 cases. Br J Dermatol 2007; 156: 705-8.
3. Zitelli KB, et al. Idiopathic facial aseptic granuloma: Review of an evolving clinical entity. Pediatr Dermatol 2015; 32: e136-9.
4. Shams AA, et al. Idiopathic facial aseptic granuloma; A rare, benign pediatric dermatological lesion. Otolaryngol Head Neck Surg. 2015 Oct;153(4):693-4.
5. Baroni A, et al. Idiopathic facial aseptic granuloma in a child: A possible expression of childhood rosacea. Pediatr Dermatol 2013; 30: 394-5.
6. González Rodíguez AJ, Jordá Cuevas E. Idiopathic facial aseptic granuloma. Clin Exp Dermatol 2015; 40: 298-300.

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