Assessment of Treatment of Refractory Granuloma Faciale With Intralesional Rituximab

Abstract

IMPORTANCE Granuloma faciale (GF) is a rare, benign inflammatory dermatosis of unknown cause. Some reports have suggested that it could be part of the spectrum of IgG4-related sclerosing diseases. Granuloma faciale is characterized by single or multiple red-brown nodules, most frequently occurring on the face, and it can produce severe disfigurement. Treatment is difficult, and poor outcomes are often seen. Rituximab is a monoclonal antibody against CD-20 approved by the US Food and Drug Administration for treatment of some autoimmune and tumoral diseases.OBJECTIVE To evaluate the treatment of refractory GF with intralesional rituximab. DESIGN, SETTING, AND PARTICIPANTSIn this case series, 3 patients with biopsy-proved refractory GF who underwent treatment at a dermatology outpatient clinic of a tertiary referral hospital were evaluated. The study was conducted from August 2015 to December 2017.INTERVENTIONS Doses of 0.5 to 1 mL/cm 2 of intralesional rituximab, 10 mg/mL, were administered monthly for 6 months and thereafter depending on clinical response. In 2 patients, peripheral blood B-cell counts were monitored before and during treatment, and in 1 patient, only during treatment. MAIN OUTCOMES AND MEASURESReduction in size of the lesions, ultrasonography evaluation, subjective improvement, and adverse events were monitored throughout the course of therapy.RESULTS All 3 of the patients were men (ages from 30s to 60s). They showed a significant reduction in the size and thickness of GF both clinically and on ultrasonography evaluation. Two patients had a complete response and the third, a partial response. A reduction in peripheral blood B-cell count was observed in the 3 patients, suggesting that the action of rituximab could be systemic. No severe adverse reactions were reported.CONCLUSIONS AND RELEVANCE Intralesional rituximab may represent a novel and well-tolerated therapy for refractory GF.

Intralesional biologics for inflammatory dermatoses: A systematic review

“…Three patients in one uncontrolled prospective trial received IL‐rituximab, a chimeric murine‐human monoclonal antibody directed against CD20, at 5–10 mg monthly, with two (66%) experiencing CR (defined as >75% improvement) and a reduction in peripheral B‐cells, and 1 (33%) experiencing PR. Side effects included injection site pain, and mild leukopenia in 1 patient 13 …”

Refractory granuloma faciale successfully treated with adjunct topical JAK inhibitor

“…Although usually asymptomatic, GF can cause severe pruritus with impact on quality of life as observed in this case. 3 Management remains challenging given its persistent nature and lack of consensus on treatment. Another layer of complexity is added in patients with comorbidities such as in this case.…”

“…Other therapies used with limited available evidence of efficacy include dapsone gel, lasers, systemic steroids, antimalarials, clofazimine, adalimumab, and intralesional rituximab. 2 , 3 …”

Unusual keloidal granuloma faciale recalcitrant to several treatments

“…However, more recent studies have shown good results after four months with topical tacrolimus 0.1% [10]. Meanwhile, other studies have shown good and promising results with intralesional rituximab [11].…”